PPACA Links: 2013-08-08
Readers, I'm sorry that Monday slipped into, er, very late Thursday, but I've been consumed with housepainting. --lambert
Is Choosing a Health Plan Like Buying a Car or Canned Goods? Trudy Leiberman, Prepared Patient Blog 2010-06-21
The hope is that patients will also become good consumers, always choosing the best options whether it's a doctor, hospital, or an insurance policy. The danger is that if they don't, and things go wrong, they will be blamed for the bad outcomes. An ethicist I heard speak recently was troubled by all the emphasis on health care choice which she called simplistic market rhetoric. The emphasis on choice blames the victim for not reading the fine print when they have made a wrong one, she said.
That brings me to the problem of Medicare Advantage plans and the apparent wrong decisions millions of seniors are making. The Centers for Medicare and Medicaid Services (CMS), which runs the Medicare program, rates Medicare Advantage plans using a star system'the more the better. The stars supposedly offer clues about plan quality including whether plan members get timely screenings and vaccinations and how how quickly they respond to complaints.
As someone who helped invent health plan ratings in a previous job, I've come to agree with that assessment, and that raises the fundamental question of how useful all these stars and bars are in the first place. To find out, I did a quick survey of the Medicare Advantage plans that are available in Manhattan where I live. There are 103 choices, way too many for the average senior to wade through and make an intelligent decision. Most people would throw up their hands and ask their best friends or run for the nearest insurance agent to help narrow the choices.
Once you make those decisions and start inspecting the stars, you run smack into another problem. Many of the plans have the same ratings. Looking at the stars that summarize all of the quality dimensions, I find that Aetna's standard plan HMO rates three stars but so does its value plan HMO. So does GHI's PPO II and Healthfirst's 65 Plus Plan HMO. And how much better are these plans than the Fidelis Medicare Advantage Part B Reduction HMO-POS, or for that matter, Aetna's standard plan PPO? They merit three and a half stars. Then there are a slew of plans for which there is too little information to rate.' That would turn a shopper off right there.
Lambert here: This post is an oldie but goodie from 2010. It will be interesting to see if the ObamaCare Exchanges learned anything from the Medicare Advantage experience; I'm guessing no.
Medicare’s New Tactic—No Admission Affordable Care Act Review, 2013-07-30
In one of the most unique approaches to addressing Medicare payment issues, CMS issued a notice on July 26, 2013 that, in certain American counties, it was unilaterally suspending, effective July 30, 2013, the creation of new Medicare providers in ambulance services and home health agencies. The suspension is for a six (6) month period and may be unilaterally extended by CMS in six (6) month increments. To date, these moratoria are limited principally to Cook and Miami-Dade counties following decades of focus on the States of Illinois, New York, Florida, Texas and California as sites of Medicare and Medicaid fraud. Citing, among other provisions of the Affordable Care Act, Section 1866(j)(7) of the Act, CMS believes that it has the authority to make unilateral determinations of whether providers will be approved regardless of quality or financial strength. In pertinent part, CMS quotes from the Act that language that empowers the Secretary of HHS to impose the moratorium “if the Secretary determines such moratorium is necessary to prevent or combat fraud, waste, or abuse under either such program.” Exacerbating this announcement is the claim by CMS that rights of appeal will be extraordinarily limited.
In my 32 years of practice, I have never seen this tactic used before. … CMS may not be able to police its providers quickly enough for their own satisfaction. That failure should not be justification for federal determinations of whether a state has enough providers of a particular type.
Lambert here: I've been noticing a continuing story of "small fish" Medicare fraud indictments. Obama being Obama, I have to believe these are meant to lay the groundwork for a full-scale assault on the program. So this is a troubling precedent (and since Cook County is Rahm's patch, you have to believe he knew about it). Will approval of other types of provider be unilaterally suspended? And catch the administration doing anything about "waste, fraud, and abuse" by banks!
The Unanticipated Consequences of Postponing the Employer Mandate NEJM, 2013-07-31
But the demise of the employer mandate has a potentially more important side effect: it removes incentives for employers to offer coverage to lower-income workers at low enough explicit premiums that they would choose job-based coverage over exchange coverage. The ACA sought high “target efficiency” — aiming subsidies only at lower-income uninsured people without a large-group insurance option and avoiding having subsidies claimed by people at the same income level who already have large-group insurance. This goal was buttressed politically by the view that employers should pay their “fair share” of the cost of coverage out of their profits (despite strong economic arguments that workers ultimately pay for mandated benefits through lower wages or job loss2,3). To restrain lower-income workers from swapping employer insurance for exchange insurance, the regulations required employers with at least 50 employees to offer coverage with low enough explicit premiums to keep the group alternative more attractive.
With that threat gone, it may make sense for employers and lower-wage workers to implicitly agree to a deal whereby such workers buy insurance through exchanges using government-financed subsidies and are “made whole” through higher wages. Higher-income workers could still choose group insurance, taking advantage of their larger tax break.
Lambert here: Show of hands: How many of you think employers will make the employees whole?
Wellpoint expects $20 billion PPACA windfall Benefits Pro, 2013-07-31
WellPoint trumpeted that good news during an analyst conference call last week to discuss second-quarter results. Not only did its quarterly results beat analysts’ expectations, but newly minted CEO Joseph Swedish said the company expects a windfall of sorts from the Patient Protection and Affordable Care Act — as much as $20 billion by 2016.
Lambert here: That shouldn't be surprising; Wellpoint VP Liz Fowler wrote the bill when on secondment to Max Baucus's office as chief of staff. Incidentally, since nobody can show what benefit insurance companies bring to any health care transaction, that $20 billion of rental extraction is pure waste.
Employers increasingly relying on wellness programs Health Reform Talk, 2013-07-31
Just 32 percent of companies that offer wellness programs said they have been able to determine the return on investment (ROI) of their companies’ programs.
Lambert here: Notice that the article doesn't say what the ROI actually is.
Low-Socioeconomic-Status Enrollees In High-Deductible Plans Reduced High-Severity Emergency Care Health Affairs, August 2013
One-third of US workers now have high-deductible health plans, and those numbers are expected to grow in 2014 as implementation of the Affordable Care Act continues. There is concern that high-deductible health plans might cause enrollees of low socioeconomic status to forgo emergency care as a result of burdensome out-of-pocket costs. We analyzed emergency department (ED) visits and hospitalizations over two years among enrollees insured in high-deductible plans through small employers in Massachusetts. We found that plan members of low socioeconomic status experienced 25–30 percent reductions in high-severity ED visits over both years, while hospitalizations declined by 23 percent in year 1 but rose again in year 2. Similar trends were not found among high-deductible plan members of high socioeconomic status. Our findings suggest that plan members of low socioeconomic status at small firms responded inappropriately to high-deductible plans and that initial reductions in high-severity ED visits might have increased the need for subsequent hospitalizations.
Five Things To Know About Obamacare Premiums: A Guide For The Perplexed Kaiser Heath News 2013-08-01
 Premiums are just one part of the cost of health insurance. When considering a report on rates, ask which type of coverage was highlighted and how much the deductibles and co-payments are. Was it the low-cost bronze plan price, the slightly higher priced silver plans or the highest priced platinum or gold? Or some combined average?  Many of the estimates are based on averages, which really don’t reflect what any individual consumer will pay. Premium prices will vary based on a person’s age, where they live and the insurer they select. Generally, younger people – especially those few who are buying high-deductible coverage now -- may see an increase in premiums, while older or less healthy people may see their rates go down.
Health Industry Price Inflation At Historical Low Heath Affairs Blog, 2013-08-01
According to [The Altarum Insitute's] analysis, the health sector pricing trend ran at a 1.0 percent annual rate in May 2013, lowest since January of 1990. What is striking about Altarum’s health care pricing trendline is that it has declined for the last three years in spite of an alleged economic recovery. … Since the beginning of the recession, pricing has subsided from double the rate of the GDP deflator to parity, and it has closely tracked the deflator with only two deviations for more than eight years. Clearly, something more than the recession is at work here. … My economist friends point to rising consumer copayments as inhibiting price increases. … There is no actuarial roadmap to guide health insurance pricing in an environment where most traditional underwriting strategies have been outlawed by ACA. Guaranteed issue and guaranteed renewal, elimination of lifetime caps, prohibitions on pre-existing conditions restrictions, enrollment of children to age 26 on their parents’ policies all have costs that must be spread across insurers’ risk pools. Optimism about private insurer pricing in 2014 has given way to watchful waiting and anxiety. Yet the Altarum Report confirms that if one is to embark on an aggressive program of health insurance expansion and public subsidy, there could hardly be a more propitious time than right now. Sustained relief from rising health costs could help alleviate fiscal pressure on government budgets and on the broader economy.
Are doctors ethically obligated to sign patients up for Obamacare? KevinMD, 2013-08-02
Society expects much from physicians, much more than we expect from politicians. The medical profession rightly demands much of itself. I hope that even the most militantly anti-Obamacare doctors will recognize that their primary duty to their patients requires that they help them sign up for Obamacare coverage, even if they wish to continue to engage in the political process to get it changed or even repealed.
Obamacare foes shouldn’t obstruct personal coverage Bellingham Herald, 2013-08-04
One delusion of the refuse-to-enroll campaign was summed up recently by a tea party activist in Michigan.
“When you need help,” she told the Washington Post, “you should go to your neighbors and church. It’s the American way of doing charity.”
That’s a pretty thought. In the real world, people don’t go to their neighbors and churches when they fracture their skulls in motorcycle crashes or get pregnant unexpectedly. They go to emergency rooms. When the uninsured guy won’t or can’t pay, the hospital shifts the cost of his care to government and private insurers – which pass it on to the public in the form of higher taxes and premiums.
HHS is shielding Obamacare outreach from sequester cuts Sarah Kliff, WaPo 2013-08-05
“We’re going to do our best outreach to [young adults],” [HHS Secretary Kathleen Sebelius says. “We know a lot of young adults don’t have health insurance as their top priority and reaching that group is a challenge. I do know that the target population is front and center on insurance companies’ target lists.” Insurance plans want to sign up young adults for the same reason that the White House wants them to enroll: Their lower health care costs would likely lower the cost of premiums. Lower premiums, from an insurers’ perspective, means an easier sell.
Lambert here: Notice how ObamaCare (and what a misnomer "Care" is) isn't prioritizing outreach to those who need care. Rather, it's focusing on the actuarial sounds of the program, as if HHS were a private insurance company. This not only immoral, it's cognitive regulatory capture of a very high order.
Obamacare Depends on Math of Matt Saniie From Campaign Data Cave Bloomberg, 2013-08-05
The success of President Barack Obama’s health-care plan depends on signing up millions of uninsured Americans, and Matt Saniie knows how to find them. Fresh out of the Obama re-election campaign “Data Cave,” the 31-year-old math whiz has gone from tracking likely voters in battleground states to honing a statistical model that can predict with 99 percent accuracy whether someone has insurance. Obama and his backers, facing a Republican move to disrupt the start of the insurance marketplaces that are at the core of the law, are adapting the techniques of his election wins. [Oh. I always thought that was the plan all along.] That includes cutting-edge data analysis, a heavy investment in personal canvassing and social media -- and a bet that they can generate enthusiasm among young Americans. “The Obama people are not stupid: They know how to campaign and who to go after,” said Uwe Reinhardt, a health-economics professor at Princeton University in New Jersey. Because the government will offer billions of dollars in subsidies to help people buy insurance, he said, “There are enough young people with pretty low incomes that for them this is a pretty good bargain.” … [T]his campaign is an all-out effort to get to 2.7 million -- the number of healthy 18- to 34-year-olds that White House officials say they need to sign up when open enrollment begins on Oct. 1. … The model that Saniie developed, which scores the probability that anyone is covered by insurance on a 0 to 100 percent scale, helps Planned Parenthood and other groups promoting the insurance marketplaces target their efforts. … Enroll America already has deployed 80 salaried field organizers to 10 states to begin campaigns on insurance signup.
“We have volunteers who maybe have a couple hours on Saturdays to have conversations,” said Anne Filipic, 31, the group’s president, who ran Obama’s first statewide canvass in Iowa in 2007 and left a White House position to take on this mission. “The fact that we can double our efficiency or maybe more makes every aspect of our work more effective.”
Lambert here: This seems to be a follow-on to WaPo's hagiography of David Simas, just with a different tech dude. I don't get how this works. Aren't we assuming the conversion rate for buying health insurance is the same as the conversion rate for voting for a political candidate? Why should that be true?
Criminal Charges for Providers Won’t Fix the NHS, Dr. Berwick The Health Care Blog, 2013-08-06
Don Berwick, who worked on the long fought for Obamacare provisions in the US, is director and co-founder of the Institute for Healthcare Improvement in Boston. He was called in by the government to reflect on the Francis report and on patient safety.
Berwick’s review makes ten recommendations including that sufficient staff are available to meet the NHS’s needs now and in the future – staff should be well-supported and able to ensure safe care at all times; quality and safety sciences and practices should be a part of the initial preparation and lifelong education of all health care professionals, including managers and executives; and leaders should create and support learning and subsequently change, at scale, within the NHS.
But most controversial is his final recommendation:
We support responsive regulation of organizations, with a hierarchy of responses. Recourse to criminal sanctions should be extremely rare, and should function primarily as a deterrent to willful or reckless neglect or mistreatment.
Berwick proposes the government creates a new general offence of “willful or reckless neglect”, applicable both to organisations and individuals. Organizational sanctions might involve removing leaders and disqualifying them from future leadership roles, public reprimand of the organization and, in extreme cases, financial sanctions – but only where that will not compromise patient care.
Lambert here: Oddly, or not, nobody in the Obama administration is proposing new forms of criminal sanction for banksters -- or cops. So it's quite clear which classes are privileged in this conversation, and which are not. Tin foil hat time: I can't shake the feeling that there's a concerted campaign against the NHS -- one that will cheerfully put patients' lives at risk -- which will at some point cross the Atlantic and be used to attack Medicare and defend ObamaCare. Awarding a big contract to SERCO, a UK company, would chime with that; they would be potential beneficiaries of an NHS privatization scheme, and could use their ObamaCare contracting as a selling point.
WebMD launches online ObamaCare guide The Hill, 2013-08-06
WebMD on Tuesday announced its new "Health Care Reform Center," which guides users through the basics of the Affordable Care Act and how to purchase health insurance on the new exchanges.
WebMD is part of a growing group of healthcare stakeholders working to educate the public before ObamaCare's major provisions take effect on Jan. 1.
AARP on Monday launched two information sites on the reform, and Walgreens, CVS and the Blue Cross Blue Shield Association are working to promote the law's benefits.
These efforts are likely to come as a relief to the Obama administration. Health and Human Services (HHS) Secretary Kathleen Sebelius lamented Monday that she does not have the resources she would like in order to promote the law.
Lambert here: Here is the WebMD site; here are the first and second AARP sites. If any of these sites convey to anyone that ObamaCare is going to like buying "a flat screen TV" send me a hat by surface mail, and I'll eat it. (Obots not eligible.)
CVS Is Pushing Obamacare. Will it Backfire? Businessweek, 2008-08-06
CVS Caremark (CVS) recently announced that it would use its retail stores to promote the new health law to uninsured Americans who will be eligible to buy coverage through new online insurance marketplaces, starting on Oct. 1. Stores may host so-called “navigators,” who will be employed by states to act as advisers helping people enroll; this means that confused shoppers could walk into a CVS store armed with questions and walk out having figured out which health plan suits them best. Walgreen (WAG) last month made a similar announcement that it would help get the word out about Obamacare’s options online and in stores. … CVS operates 684 clinics in stores and plans to have nearly 800 by yearend. The company sees opportunity with so many new patients getting insurance and not enough primary care doctors to treat them. “Our longer term goal is to create a national primary care platform,” Chief Executive Larry Merlo said on the call today. Helping people sort through their health-plan choices just might be a natural fit.
Where Obamacare premiums will soar CNN, 2013-08-06
While many residents in New York and California may see sizable decreases in their premiums, Americans in many places could face significant increases if they buy insurance through state-based exchanges next year.
That's because these people live in states where insurers were allowed to sell bare-bones plans and exclude the sick, which has kept costs down. Under Obamacare, insurers must offer a package of essential benefits -- including maternity, mental health and medications -- and must cover all who apply. But more comprehensive coverage may lead to more expensive insurance plans.
Under Obamacare, all Americans must have insurance coverage starting in 2014 or face penalties of $95 or 1% of family income, whichever is greater. Enrollment in the exchanges begins October 1, with coverage kicking in in January. Plans will come in four tiers, ranging from bronze to platinum.
Some lightly regulated states, including Indiana, Ohio, Florida and South Carolina, have recently released preliminary rate information highlighting steep price increases. Unlike the blue states of California and New York, these are Republican-led states that have strongly opposed the Affordable Care Act, as Obamacare is officially known.
Last week, I wrote about Enroll America’s plan to go door-to-door to urge uninsured people to sign up for health insurance, in some cases returning a half-dozen times to convey the message. But will a knock on the door – or eight – be enough?
Maybe not, according to Stan Dorn, a senior fellow at the Urban Institute, whom I quoted in the piece and who is skeptical of such efforts. He thinks the only way to get large numbers of people signed up quickly is to actually do the signing up for them.
“It’s human nature not to complete forms or paperwork,” he said. “The initiatives that have succeeded in enrolling large numbers of people have eliminated the need for consumers to fill out paperwork.”
In our conversation, he cited a few studies to illustrate his point, including one from 2005 that examined company 401(k) plans. When workers had to fill out paperwork before the accounts were created, about 33 percent of workers participated, he said. But participation spiked to 90 percent when companies automatically established the accounts, with an option for workers to opt out.
He also pointed to some experiments looking at H&R Block’s efforts to help their tax clients enroll in public benefits. In one, the tax preparation company filled out the paperwork for clients eligible for SNAP. As helpful as it was to simply fill out the forms, participation in the food assistance program was 80 percent higher when the company took the extra step of submitting the paperwork on the clients’ behalf.
Lambert here: Oh well. Still, even if Enroll America just ends up confirming addresses, that will be useful for Campaign 2014.
Preparations for Health Exchanges on Tight Schedule Online WSJ, 2013-08-07
With time running short before enrollment kicks off Oct. 1, the Obama administration last week cut back on training requirements for these "navigators."
Grants to hire and train the workers aren't expected to be released for another two weeks for the 34 states where the federal government is running all or part of the marketplaces, which will offer insurance to those who don't get it on the job or from Medicare or Medicaid. That leaves just 32 business days to hire and train thousands of helpers in these states.
"It's definitely a tight timeline, and there's a lot to do before Oct. 1," said Jen Bersdale, executive director of Missouri Healthcare for All, a nonprofit advocacy group helping coordinate outreach activities in the state. "I imagine some people will be working overtime to do it."
The Affordable Care Act: A User’s Guide California Health Report, 2013-08-07
Our current system pays providers for specific services, for instance, but the industry is moving towards a system where providers are paid per patient instead. Under this system, doctors or practices receive bonuses when their patients do well, including going to follow-up appointments, avoiding the emergency room, and seeking appropriate care for chronic conditions. So far there have been mixed results for these pay for performance initiatives — sometimes they improve care but often they don’t. Accountable Care Organizations, which rely on a network of health professionals coordinating care to improve the health of their patients and reduce costs, aren’t working as expected either. Adjusting to new systems takes time, as long as five to six years, ACO organizations suggest, but that also means that reducing costs will take time too.
Lambert here: Medicare took a year to implement, back in the Age of Steam, when LBJ was president. So if Medicare for All had been passed in 2010, we would have saved $600 billion in 2011, and another $600 billion by the end of this year. All this crapola about bending the cost curve, and experimenting with different systems of health care delivery is code for one thing: Preserve the health insurance industry at all costs. Because we already know single payer works; it's tested, tried, and true. So why are we even experimenting with ObamaCare?
A Conservative Re-Envisioning Of The Health Care Overhaul Kaiser Health News, 2013-08-07
[The new report,] discussed at an AEI forum Tuesday, would keep key elements of the 2010 health care law – its online marketplaces, or exchanges, where people purchase coverage, and its subsidies to help people buy coverage – but structure them differently. The AEI plan includes national or state run exchanges, but insurers would face far fewer restrictions governing how much they could charge for coverage. And while the health law provides subsidies for individuals and families with incomes up to 400 percent of the poverty level, the AEI plan would provide subsidies to individuals with extremely high medical costs up to 600 percent of the poverty level.
Unlike the health law, however, there would be no employer or individual mandates to provide or purchase coverage or pay a fine. And the AEI plan would scrap Medicaid, the federal-state health insurance plan, and instead provide coverage through the exchanges with generous subsidies for the poorest and sickest.
Lambert: So how long will it take for the Democrats to adopt this proposal and abolish Medicaid?