Cost of Treatment May Influence Doctors
Saying they can no longer ignore the rising prices of health care, some of the most influential medical groups in the nation are recommending that doctors weigh the costs, not just the effectiveness of treatments, as they make decisions about patient care.
The shift, little noticed outside the medical establishment but already controversial inside it, suggests that doctors are starting to redefine their roles, from being concerned exclusively about individual patients to exerting influence on how health care dollars are spent.
“We understand that we doctors should be and are stewards of the larger society as well as of the patient in our examination room,” said Dr. Lowell E. Schnipper, the chairman of a task force on value in cancer care at the American Society of Clinical Oncology.
In practical terms, new guidelines being developed by the medical groups could result in doctors choosing one drug over another for cost reasons or even deciding that a particular treatment — at the end of life, for example — is too expensive. In the extreme, some critics have said that making treatment decisions based on cost is a form of rationing.
Traditionally, guidelines have heavily influenced the practice of medicine, and the latest ones are expected to make doctors more conscious of the economic consequences of their decisions — even though there is no obligation to follow them. Medical society guidelines are also used by insurance companies to help determine reimbursement policies.
The society of oncologists, alarmed by the escalating prices of cancer medicines, is developing a scorecard to evaluate drugs based on their cost and value, as well as their efficacy and side effects. It is expected to be ready by this fall.
And the American College of Cardiology and the American Heart Association recently announced that they would begin to use cost data to rate the value of treatments in their joint clinical practice guidelines and performance standards.
Some doctors see a potential conflict in trying to be both providers of patient care and financial overseers.
Enrollments Exceed Obama’s Target for Health Care Act
WASHINGTON — President Obama announced Thursday that eight million people have signed up for health insurance under the Affordable Care Act, including what the White House said were a sufficient number of young, healthy adults, a critical milestone that might counter election-year attacks by Republicans on the law’s success and viability.
The total number of enrollees exceeds by a million the target set by the administration for people to buy insurance through government-run health care exchanges. In particular, the number of young people signing up appears to have surged during the final weeks of enrollment.
“This thing is working,” Mr. Obama told reporters in the White House briefing room, in what amounted to a second victory lap after he announced two weeks ago that 7.1 million people had signed up for insurance during an initial enrollment period. “The Affordable Care Act is covering more people at less cost than most people would have predicted a few months ago.”
Still, critics of the law cautioned that promising top-line numbers were not by themselves proof of success.
Although more young people signed up for health insurance, for example, the number remained below the level that some analysts believe is optimal for keeping premiums low in the insurance marketplaces. The administration said Thursday that 28 percent of those who bought policies were between the ages of 18 and 34, but some analysts said the optimum level would be 40 percent.
“In an ideal world, you’d want to get as close to that as possible,” said Larry Levitt, a senior vice president at the Kaiser Family Foundation. “But what is important is what the insurance companies expected, and this is what they expected.”
The administration did not release two other crucial statistics that would help determine the success of the law: the number of people among the eight million who bought insurance for the first time and the number who paid their initial premiums.
The number of those who were previously uninsured is important, since many people could simply have been moved from plans that were canceled by the law. Administration officials have promised to release that information when they have it, but they have said it is not data that is collected by the government.
The Affordable Care Act comes in with better-than-expected numbers
OBAMACARE’S CRITICS have had a bad week. On Thursday, President Obama announced that 8 million people have enrolled in new health insurance plans through the Affordable Care Act’s marketplaces, and a significant portion of them are young Americans. Yes, we need to learn more about the numbers. And yes, a lot needs to happen to complete the ACA’s phase-in. The debate about how well the law is working is not over. But the initial figures are encouraging, and Mr. Obama is right to insist that continued Republican demands for repeal are unproductive and unwise.
To discount solid enrollment numbers, Republicans have variously complained that not many people who previously were uninsured may be signing up, premiums are rising, people can’t see the doctors they prefer and taxpayers are getting soaked.
But the Obama administration wasn’t the only one with a new analysis of the law this week. In its latest estimates on the effects of the ACA, the nonpartisan Congressional Budget Office found that the percentage of Americans with insurance is set to go up. The analysts projected that 84 percent of the non-elderly population will have insurance this year, instead of 80 percent before the ACA. In 2016, the share will rise to 89 percent.
The CBO found that premiums in the new marketplaces for individual insurance buyers are not as high as many experts — including the CBO itself — expected, and that they will remain below projections. This indicates that a basic trade-off embedded in the law may well be cheaper than anticipated. The ACA requires that insurance plans in the individual marketplace provide comprehensive basic health benefits to all comers, which was not the case in the old system. Some individual purchasers — those who used to have skimpy coverage, for example, or who benefited from the discrimination against the elderly and the sick on which the old system relied — will pay more. Many others, however, will not, especially after they get government assistance to buy insurance. And people with preexisting conditions or other problems will no longer be priced out. That these worthwhile reforms are not expected to result in premiums as high as experts once projected is good news for individual buyers and the federal budget. The CBO reckons that the government will save about $5 billion this year and $104 billion over the next decade.
Part of the reason for the better-than-expected premium news is that health insurers have found ways to cut costs that do not involve turning away the sick or refusing to pay for treatment of certain basic illnesses. One cost-cutter, the CBO noted, has been narrowing the networks of doctors and specialists insurance companies do business with. Patients might object, but the new marketplaces appear to be compelling providers to compete to keep costs down.
Obamacare enrollment nears 1.4 million in California exchange
By Chad Terhune
11:19 AM PDT, April 17, 2014
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Covered California signed up more than 200,000 consumers for Obamacare coverage after extending its enrollment deadline by two weeks, bringing the statewide total to nearly 1.4 million people.
The health insurance exchange gave people until Tuesday to finish enrolling after the state website faltered at the end of March from a crush of last-minute applicants.
By Tuesday, the latest deadline, 50,000 people picked a health plan.
Overall, the state exchange said about 85% of enrollees have paid their health premium thus far, so the enrollment tally may drop. It also said Thursday that 88% of exchange customers qualified for premium subsidies under the Affordable Care Act.
Another 1.5 million have enrolled or been deemed eligible for Medi-Cal, the state's Medicaid program for lower-income people. Enrollment in Medi-Cal continues all year.
The state said it continued to make gains among Latinos after a slow start during the fall. In the first half of April, Latinos accounted for 39% of enrollees compared to 18% of those signing up in October, November and December.
Overall, Latino enrollment stands at 305,106 people or 28% of total enrollment, according to state figures.
Full coverage: Obamacare rolls out
The state said people ages 18 to 34 also showed up in larger numbers at the end of open enrollment, as many experts predicted.
That coveted age group represented 29% of total California enrollment. Those young people account for 36% of people eligible for premium subsidies.
"The people enrolling kept getting younger and more diverse," said Peter Lee, executive director of Covered California.
The state also released for the first time data on how Californians signed up for Obamacare.
It said 41% of people enrolled on their own through the state website. Another big group, 40%, signed up with a certified insurance agent.
Nine percent worked with a local enrollment counselor and an equal number used the state's call center.
Covered California was faulted early on for a shortage of enrollment counselors and for not publicizing sooner the availability of free, in-person help from agents and counselors.
Many consumers complained about long wait times with the state's call center. In the first week of April, 40% of people couldn't get through and gave up their call.
State officials said some people may have gotten the information they needed from a recording while on hold.
"This has not been perfect and it won't be perfect as we go forward," Lee said.
Los Angeles County was the busiest place for enrollment with 400,889 people picking out a health plan. That figure doesn't include Medi-Cal.
The next open enrollment period starts in mid-November. People who move, lose employer coverage or have other qualifying events may be eligible for special enrollment before then.
http://www.latimes.com/business/money/la-fi-mo-covered-california-enrollment-20140417,0,6944464,print.story
Final-hours push for Maine Medicaid expansion appears headed for another LePage veto
A new proposal would use federal money allocated to expand the program to help low-income Mainers buy private insurance coverage.
AUGUSTA — House Speaker Mark Eves and the Democratic controlled Legislature made a last-ditch effort Thursday to expand Medicaid health coverage to more than 60,000 Mainers.
The latest attempt – the Democrats’ fourth – faces the same obstacles as the others: a certain veto by Gov. Paul LePage and Republican opposition that has helped the governor sustain three previous rejections.
On Thursday, the early votes and rhetoric forecast a similar ending. The House approved the bill, 94-51, but the margin was six votes short of the two-thirds majority that would be needed to override a veto. The Senate voted 19-14 to approve the bill, also short of the override threshold.
The latest expansion bill would take federal money allocated for Medicaid expansion under the Affordable Care Act and use it to help uninsured Mainers buy private insurance. The proposal, introduced as the legislative session draws to a close, differed from three other Medicaid expansion bills because the federal funds would be used to help low-income Mainers purchase private insurance coverage in the new federal marketplace rather than simply expanding eligibility for the state’s Medicaid program, known as MaineCare.
The proposal, L.D. 1578, is similar to an approach taken in New Hampshire and in Arkansas. Those efforts followed exhaustive study and debate and ultimately emerged as a compromise between Democrats, who support expansion, and Republicans, who have criticized Medicaid for inefficiencies and cost overruns.
Eves, who introduced the proposal from the House floor, said the proposal was a final good-faith effort to provide health care coverage to Mainers.
“My intention is not to score political points, but to have a conversation,” said Eves, adding the proposal was a market-based solution supported by Republicans that achieved the goal of both parties to extend health care coverage to more people.
He added, “We all want to do the right thing.”
Rep. Deborah Sanderson, R-Chelsea, said Eves was right that both parties wanted people to have health insurance but the proposal was too complicated and not properly vetted.
Maine Legislature approves late, last-ditch push for Medicaid expansion
Posted April 17, 2014, at 9:21 p.m.
AUGUSTA, Maine — The Maine Legislature on Thursday night approved a Medicaid expansion plan for the third time since March, though the bill is likely doomed to the same fate as its predecessors — death by gubernatorial veto.
The House of Representatives gave the bill final approval with a vote of 94-51. The Senate gave final approval after a 19-14 vote. Neither tally indicates enough support to override a near-certain veto by Republican Gov. Paul LePage.
The bill, as amended by House Speaker Mark Eves, D-North Berwick, was introduced to lawmakers just hours before the vote, prompting complaints from some that there had not been enough time to digest the plan before being asked to vote.
Eves’ amendment offered a new twist on the 16-month-old Medicaid expansion debate by promoting a plan to use millions of federal Medicaid dollars to buy private insurance plans for tens of thousands of newly eligible low-income Mainers.
The tone of debate on the House floor was conciliatory and brief — a stark contrast to the fiery rhetoric and lengthy floor speeches that accompanied previous bills.
“My intention this evening is not to incite another fierce debate but rather lay out the proposal and ask you to sincerely consider it and the lifesaving health care benefits it will have for your constituents,” Eves said during a floor speech.
“I sincerely believe anybody and everybody in this body who says they want coverage for these individuals,” he said. “I know that to be true for every person in this room. This is a pathway to get there.”
Eves was the only member of the House to speak in the bill’s favor. A few Republicans spoke in opposition to the bill. Their chief concern was about the short time frame representatives had to even consider the plan, which Eves sprung on the body during its last regularly scheduled day of the session.
They said the bill should be brought back during the next Legislature, after November’s election, and given a chance to go through the full legislative process.
“The amendment before us is sweeping,” said Assistant House Minority Leader Alex Willette, R-Mapleton. “It’s a massively complex policy proposal that would change our state’s Medicaid system as we know it.”
Noting the extent to which Medicaid expansion had already been debated in the prior 16 months, Sen. James Hamper, R-Oxford, said the debate was “deja vu all over again.”
Democrats emphasized how far removed the plan was from what they originally wanted — a straightforward Medicaid expansion as allowed by federal law. Eves’ bill, they said, was one final effort to try to win Republicans over.
“I will support any reasonable compromise that brings health care to more Maine people,” said Senate Majority Leader Troy Jackson, D-Allagash, in a written statement. “If we can save even one life with this compromise, to me, it’s worth it.”
Rather than simply expanding Medicaid permanently to 70,000 low-income Mainers as originally envisioned by the 2010 federal Affordable Care Act, Eves’ plan would expand Medicaid to those people for one year, while the state establishes a new system to use the money to buy private insurance plans for those recipients.
Starting in summer 2015, about 55,000 of those newly eligible Mainers — all of whom are childless adults — would be shifted to the private plan. Another roughly 15,000 parents would remain on Medicaid, known here as MaineCare.
The private-option system would be administered by the Department of Health and Human Services. If the eligible recipient has access to insurance through their employers, he or she would have to purchase it, and enrollees under the new system would be required to pay co-pays and deductibles on their own.
The bill also includes several compromises already ceded by Democrats: It sunsets after the three years of 100 percent federal funding expires, it automatically self-destructs if federal funding dips below promised levels, and it includes funding for additional welfare fraud investigators.
Maine needs transparency so residents can shop for lowest-cost, highest-quality health care
Posted April 17, 2014, at 3:11 p.m.
As a nation of seasoned shoppers, we have honed our skills at yard sales, in bargain basements and over the backyard fence. It makes common sense that we should also be informed shoppers for our health care.
Why shouldn’t we be able to find out the prices beforehand of nonemergency, elective medical procedures? Should we not know that a chest X-ray costs $87 at Rumford Hospital and $310 at Miles Memorial Hospital in Damariscotta? Or that a routine colonoscopy costs $971 at Cary Medical Center in Caribou but $3,167 at Mount Desert Island Hospital?
The Legislature has recently passed a bill that will allow patients and consumers to find out the prices of nonemergency, elective medical procedures beforehand. It is awaiting the governor’s signature. It is an important step that will allow us to decrease the cost of health care in Maine, particularly for those who have no insurance or high deductibles.
It is generally agreed that in the U.S., we can no longer afford our health care system. We spend twice as much per capita as most other first world countries. Despite this staggering investment, we rank from 17 th to 34 th on measures of quality. The health care dollars siphoned off by profit and waste are killing our businesses, competitiveness, economic development and jobs. In addition, it is quite literally killing us. The cost of medical services is so high that the 12 percent of Mainers with no or high-deductible insurance forgo preventive medical care until it is too late.
A year ago, TIME magazine devoted an entire issue to “The Bitter Pill,” an article describing our arbitrary, capricious and profit-oriented health care marketplace. It exposed the “Charge Master” to public scrutiny for the first time. This is a cost-shifting computer program that starts from the end (how much money a hospital must bring in to meet its needs) and works backwards to determine the charge for a particular service. It brings us Tylenol with a 1,000 percent markup and a complete blood count which cost $11 to perform for $157. All too often, there is no economic logic, no relationship between work done and the price charged.
Why do these charges matter? Many Americans never see their health care bills. Many are covered by government programs such as Medicare, Medicaid, the VA or public employee policies. Another significant group has work-related insurance. But for the final 12 percent — those who have high deductibles or no insurance at all — the cost of medical care can be ruinous. For them, price matters a great deal.
Bankruptcy and loss of all that they possess is only one illness away.
The bill passed by the Legislature will allow Mainers to be informed consumers and determine the cost of elective medical procedures beforehand. It requires all hospitals and outpatient facilities to prepare an individualized estimate of medical costs for an uninsured patient or those with a high deductible — to include facility, pharmacy, physician, laboratory and other fees. A price sheet and a contact phone number must be prominently posted. With this information, Maine consumers will be able to shop for the best quality at the best price. Hospitals and other providers will begin to realize that they exist in a competitive marketplace and begin to offer realistic prices.
In addition, the bill directs the Maine Health Data Organization to collaborate with other state and private entities to publicize health care costs. The Maine Health Data Organization and its website are not as well-known as it should be. The website currently lists the cost of 200 commonly performed procedures and tests at each of Maine’s 38 hospitals – as well as quality. This still represents only a small fraction of the medical procedures performed in Maine, but it is a good start. The site deserves a visit by all patients searching for high-quality, affordable health care.
Will the bill foster competition among providers and encourage patients to patronize those that offer quality at a lower price? For those fortunate enough to have good insurance, probably not. But for the 20 percent of those with no or poor insurance coverage, it will be of help.
It is a small step down the road to containing the costs of our runaway health care industry for the people of Maine.
Obama Sharply Criticizes Republicans As He Announces 8 Million Have Enrolled
Enrollment in private health insurance on federal and state marketplaces has surged in recent weeks and now totals 8 million, a feisty President Barack Obama said Thursday.
“This thing is working,” Obama said at a White House news conference in which he lambasted Republican critics of the health law, especially those in states that did not expand Medicaid eligibility, as the law allows.
“I'm sorry. I'm going to say one last thing about this -- just because this -- this does frustrate me, states that have chosen not to expand Medicaid for no other reason than political spite,” Obama said. “You got 5 million people who could be having health insurance right now, at no cost to these states -- zero cost to these states – [yet] other than ideological reasons, they have chosen not to provide health insurance for their citizens.”
The actual number of people affected is 5.7 million, the administration said. Republican leaders in Florida, Texas and other states argue that even though the federal government is paying the full cost of expansion through 2016, costs in later years would still be too high a burden. They also say they don’t trust Congress to abide by the law and maintain full federal funding.
Administration data show 3.8 million people signed up for private plans in the past six weeks --- compared to 4.2 million in the first five months after enrollment began Oct. 1. Enrollment ended March 31, though people who had trouble signing up generally had until April 15 to sign up in the 36 states relying on the federal marketplace.
The number of young adults signing up over the past five months continues to lag expectations, which could affect insurance premiums next year. Still, the number of enrollees 18 to 34 years of age rose to 28 percent in the federal exchange, up from 25 percent in March, the administration reported.
The administration did not release a state-by-state enrollment breakdown, nor did it say how many have paid their premiums or what percent of the 8 million were previously insured. California officials separately announced that 1.4 million people have enrolled, more than in any other state.
Obama’s latest defense of the Affordable Care Act comes as the mid-term congressional campaign season is heating up. Republicans have made attacking the law a focus of many campaigns.
Obama said he is frustrated with continued Republican insistence on repealing the law.
“The point is, the repeal debate is and should be over,” he said. “The Affordable Care Act is working. And I know the American people don't want us spending the next two-and-a-half years re-fighting the settled political battles of the last five years. They sent us here to repair our economy, to rebuild our middle class, and to restore our founding promise of opportunity, not just for a few, but for all.”
Doctors still make good money
In the United States, doctors on average still make at least three times the annual median household income. The lowest average income on the list of doctors for 2013 was $174,000 and in 2012, the median household income was about $51,000.
Orthopedics had the highest average earnings at $413,000, and cardiologists and urologists were not far behind. Of the 25 medical specialties listed, three-quarters of them had an increase from 2012, according to the Medscape Physician Compensation Report, an annual survey of doctors around the country.
Orthopedics had the highest average earnings at $413,000, and cardiologists and urologists were not far behind. Of the 25 medical specialties listed, three-quarters of them had an increase from 2012, according to the Medscape Physician Compensation Report, an annual survey of doctors around the country.
With the implementation of health insurance exchanges as part of the Affordable Care Act, just over half of the doctors were not sure if they would participate or not, and one in five said no. When asked about the effect on income, half thought it wouldn’t change much. Only 7 percent expected an increase. Most doctors say they will still take new and current Medicare and Medicaid patients, but about one-fourth of them haven’t decided
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