Anthem sued over limited networks
A similar suit seeking class-action status was filed June 20 in Los Angeles County Superior Court against Anthem, a unit of WellPoint Inc. And in May, two San Francisco residents sued Blue Shield of California, alleging it misled them into believing their policies would cover the full network.
The three lawsuits indicate that exclusive provider organization, or EPO, health plans sold under the Affordable Care Act have been particularly troublesome for some consumers who are accustomed to preferred provider organization, or PPO, policies.
In the latest case, for instance, one of the plaintiffs is a physician, Dr. Betsy Felser of Los Angeles, who alleged that she was fraudulently induced into buying a plan with a drastically reduced network of providers.
"I believed I had purchased a PPO plan, but only found out at my son's initial doctor's appointment that [Anthem] Blue Cross had sold me an EPO plan," she said in a statement. The lawsuit stated that Anthem never notified her that it didn't even offer a PPO plan in the area.
In the June 20 action, Samantha Cowart of Fallbrook accused Anthem of misleading customers by enrolling them in an EPO plan that limited access to out-of-network care even more than the PPO plan she and others previously had.
But Anthem sent Cowart an insurance card in February labeling her coverage as a PPO, resulting in several thousand dollars in medical bills that Anthem wouldn't cover, she said.
"I didn't have the regular PPO I thought I had," Cowart said.
The Physical Exam as Refuge
Obscure Rule Restricts Health Law’s Expansion of Care for Addicts
EAST HAZEL CREST, Ill. — On its surface, the Affordable Care Act seems like a boon for addiction treatment centers like the South Suburban Council on Alcoholism and Substance Abuse, housed in a no-frills former hotel outside Chicago.
The law allowed states to expand Medicaid to many more low-income people, meaning that drug addicts and alcoholics who were previously ineligible could now receive coverage for substance abuse treatment, which the law has deemed an “essential health benefit.”
But there is a hitch: Under an obscure federal rule enacted almost 50 years ago, Medicaid covers residential addiction treatment in community-based programs only if they have 16 or fewer beds. The South Suburban Council’s main treatment program has 48. So the very people who might have flowed through its doors in search of care will not be coming. And the same problem faces many other centers, which typically are larger than 16 beds, experts say.
he quirk in the law could have a significant impact on substance abuse treatment in Illinois and the 25 other states that have expanded Medicaid under the health care law. While millions of low-income addicts have been promised access to treatment through the expansion, the rule will most likely prevent many from entering residential programs, a more intensive form of care, even as heroin addiction is surging in many states.In California, for instance, nine out of 10 addiction treatment beds are in programs too large to get Medicaid reimbursement.
“For some addicts, there is an undeniable and essential need for residential treatment,” said Allen Sandusky, the South Suburban Council’s chief executive. “The A.C.A. is going to mess that up badly unless this problem is acknowledged and addressed.”
The rule was intended to prevent Medicaid funds from covering treatment in state psychiatric hospitals, which were far more common when it was written in 1965. The federal government considered such treatment a state responsibility, and it included residential programs for substance abuse under the exclusion.
Suit Against Obama to Focus on Health Law, Boehner Says
WASHINGTON — Speaker John A. Boehner’s lawsuit against President Obama will focus on changes to the health care law that Mr. Boehner says should have been left to Congress, according to a statement issued Thursday by the speaker’s office.
By narrowly focusing the legal action on the Affordable Care Act, Mr. Boehner will sidestep the more politically problematic issue involving Mr. Obama’s executive action offering work permits for some illegal immigrants who were brought to the United States as children.
Last month, Mr. Boehner announced his intention to seek legislation allowing the House to sue the president over his use of executive actions, a reflection of charges by congressional Republicans that the president has overreached his authority. On Thursday, Mr. Boehner said the lawsuit would specifically challenge the president’s decision to delay imposing penalties on employers who do not offer health insurance to employees in compliance with the Affordable Care Act.
“The current president believes he has the power to make his own laws — at times even boasting about it,” Mr. Boehner said in his statement. “He has said that if Congress won’t make the laws he wants, he’ll go ahead and make them himself, and in the case of the employer mandate in his health care law, that’s exactly what he did.”
“If this president can get away with making his own laws, future presidents will have the ability to as well,” the speaker added. “The House has an obligation to stand up for the legislative branch, and the Constitution, and that is exactly what we will do.”
Representative Nancy Pelosi, the Democratic leader in the House, called the suit a “legal boondoggle doomed to fail.”
Race Is On to Profit From Rise of Urgent Care
by Julie Creswell
NORWALK, Conn. — Start in Room 4, just beyond the reception area: A man is having blood drained from a bruised finger. Over in Room 1, a woman is being treated for eye trouble. Next door, in Room 2, a boy is having his throat swabbed.
For more than eight hours a day, seven days a week, 52 weeks a year, an assortment of ailments is on display at the tidy medical clinic on Main Avenue here. But all of the patients have one thing in common: No one is being treated at a traditional doctor’s office or emergency room.
Instead, they have turned to one of the fastest-growing segments of American health care: urgent care, a common category of walk-in clinics with uncommon interest from Wall Street. Once derided as “Doc in a Box” medicine, urgent care has mushroomed into an estimated $14.5 billion business, as investors try to profit from the shifting landscape in health care.
The office here is part of PhysicianOne Urgent Care. Bankrolled by two private investment companies, PhysicianOne has grown into an eight-clinic operation, the largest of its kind in Connecticut, with plans for even greater expansion.
But what is happening here is also playing out across the nation, asprivate equity investment firms, sensing opportunity, invest billions in urgent care and related businesses. Since 2008, these investors have sunk $2.3 billion into urgent care clinics. Commercial insurance companies, regional health systems and local hospitals are also looking to buy urgent care practices or form business relationships with them.
The business model is simple: Treat many patients as quickly as possible. Urgent care is a low-margin, high-volume proposition. At PhysicianOne here, most people are in and out in about 30 minutes. The national average charge runs about $155 per patient visit. Do 30 or 35 exams a day, and the money starts to add up.
Who Wants a Depression?
by Paul Krugman
One unhappy lesson we’ve learned in recent years is that economics is a far more political subject than we liked to imagine. Well, duh, you may say. But, before the financial crisis, many economists — even, to some extent, yours truly — believed that there was a fairly broad professional consensus on some important issues.
This was especially true of monetary policy. It’s not that many years since the administration of George W. Bush declared that one lesson from the 2001 recession and the recovery that followed was that “aggressive monetary policy can make a recession shorter and milder.” Surely, then, we’d have a bipartisan consensus in favor of even more aggressive monetary policy to fight the far worse slump of 2007 to 2009. Right?
Well, no. I’ve written a number of times about the phenomenon of “sadomonetarism,” the constant demand that the Federal Reserve and other central banks stop trying to boost employment and raise interest rates instead, regardless of circumstances. I’ve suggested that the persistence of this phenomenon has a lot to do with ideology, which, in turn, has a lot to do with class interests. And I still think that’s true.
But I now think that class interests also operate through a cruder, more direct channel. Quite simply, easy-money policies, while they may help the economy as a whole, are directly detrimental to people who get a lot of their income from bonds and other interest-paying assets — and this mainly means the very wealthy, in particular the top 0.01 percent.
The story so far: For more than five years, the Fed has faced harsh criticism from a coalition of economists, pundits, politicians and financial-industry moguls warning that it is “debasing the dollar” and setting the stage for runaway inflation. You might have thought that the continuing failure of the predicted inflation to materialize would cause at least a few second thoughts, but you’d be wrong. Some of the critics have come up with new rationales for unchanging policy demands — it’s about inflation! no, it’s about financial stability! — but most have simply continued to repeat the same warnings.
Who are these always-wrong, never-in-doubt critics? With no exceptions I can think of, they come from the right side of the political spectrum. But why should right-wing sentiments go hand in hand with inflation paranoia? One answer is that using monetary policy to fight slumps is a form of government activism. And conservatives don’t want to legitimize the notion that government action can ever have positive effects, because once you start down that path you might end up endorsing things like government-guaranteed health insurance.
But there’s also a much more direct reason for those defending the interests of the wealthy to complain about easy money: The wealthy derive an important part of their income from interest on bonds, and low-rate policies have greatly reduced this income.
Maine nonprofit plans new ad campaign for Affordable Care Act signups
The Maine Health Access Foundation will target hard-to-reach populations and those who are reluctant to sign up for benefits.
A nonprofit organization that ran a major promotional effort last year to encourage uninsured Mainers to sign up for benefits under the Affordable Care Act is gearing up for another ad campaign to begin after the November elections.
The Maine Health Access Foundation spent $600,000 on marketing and advertising, including for the enroll207.com website. Wendy Wolf, the organization’s president and CEO, said Thursday the foundation considered cutting the advertising campaign in half for 2014-15, but ultimately decided against the reduction.
“You only get one chance to do this right,” she said. “This is our moment in time, and we need to make hay while we can.”
Because Maine did not set up its own insurance marketplace through the health law, the state’s federal funding for advertising was limited. Under the Affordable Care Act, states that ran their own marketplaces received much more funding per capita than states that let the federal government run the site, Wolf said.
That’s when the foundation stepped in to help raise awareness, Wolf said. But even with the foundation money, Maine’s advertising budget did not approach that of states like West Virginia, Colorado or Washington.
The health insurance marketplace allows individuals – often self-employed or part-time employees without health insurance – to compare plans, shop for coverage and qualify for help in buying it.
Even though Maine did not spend much to promote the law, enrollment exceeded first-year expectations, with more than 44,000 people choosing a marketplace plan. About 10 percent of Mainers were uninsured in 2012, before the marketplace opened, according to the Kaiser Family Foundation, compared to 15 percent in the United States. A Gallup poll released in July found that the U.S. uninsured rate has declined to 13.4 percent in 2014, although state-by-state figures are not yet available.
The foundation spent money on its website, and television, print and online media.
Wolf said her group decided it needed fresh ads this year.
“The first wave were those ready and willing to sign up for insurance,” Wolf said. “The next group is going to be a tougher nut to crack.
Obamacare leads to massive drop in uninsured
Gallup reports that the percentage of uninsured Americans is at its lowest point since they started measuring it in 2008.
Healthcare Pay-For-Performance Folly
By Stephen Kemble, M.D.
Honolulu Star-Advertiser, July 9, 2014
Honolulu Star-Advertiser, July 9, 2014
Hawaii physicians are being offered contracts to join a “clinically integrated physician network” (CIPN) with Queen’s Medical Center through one of the local physician organizations. This is the next phase in implementation of health care payment and delivery system reforms envisioned under the Affordable Care Act.
The Centers for Medicare and Medicaid Services (CMS) is encouraging integrated networks of doctors and hospitals to form organizations that can assume financial risk for the cost of health care through initiatives such as bundled payments, shared savings and capitation.
The rationale for these reforms originated with policy leaders in Washington allied with the health insurance industry, and it is the same rationale used for HMOs two decades ago. The assumption is that U.S. health care costs are so high because we deliver and consume too much health care due to fee-for-service incentives.
When insurance risk is shifted to doctors and hospitals, they will have a financial incentive to deny care, instead of the insurance companies doing that. This creates obvious ethical conflicts for doctors and hospitals, whose traditional ethical responsibility has been to assure care to those who need it. To counter this perverse incentive and discourage arbitrary denial of care, CMS is encouraging pay-for-performance by developing data systems to more closely track the details of health care delivery, with financial rewards and penalties for scoring well or poorly on quality measures.
Never mind that most of health care is too complex to allow meaningful, valid measures of quality for more than about 5 percent of health care. Never mind that payment for narrow measures diverts attention and resources away from the 95 percent of health care that cannot be measured. Never mind that far more cost-effective health care systems than ours pay physicians with fee-for-service and don’t try to micromanage care.
Never mind that pay-for-performance carries an incentive to avoid caring for sicker, more complex patients. Never mind that tying payment to performance measures leads to widespread gaming of documentation, so the measures become disconnected from reality while costs rise. Never mind that the cost of data systems and administration required for pay-for-performance, plus the bonuses for doctors who are already practicing cost-effectively, will exceed any possible savings.
And in Hawaii, never mind that we had a low rate of procedures and the lowest per capita Medicare spending in the country before any of these reforms were introduced, under a fee-for-service payment system, so the rationale for these reforms does not even apply here.
However, Hawaii’s governor and Legislature feel compelled to respond to the incentives in the Affordable Care Act, so we have embarked on a journey of health care transformation. Hawaii’s initiative has so far been funded almost entirely by the health insurance plans and hospitals, and reflects their biases and self-interest.
Unfortunately, our transformation effort is not based on evidence of what works. Evidence-based policy means making the effort to separate ideology, rationalized self-interest, and wishful thinking from the actual outcomes of policies that have been implemented somewhere.
Policy outcomes research tells us that the reforms we are pursuing will result in increased total cost of health care, mixed results on quality with more negative than positive, and deterioration in the care experience for patients, doctors and hospitals. Our early experience so far with reform in Hawaii is confirming these predictions.
What happened to the “Triple Aims” of improved quality of care, improved population health and reduced cost? Apparently they are just empty rhetoric used as a smokescreen while those with money and power take us in the opposite direction.
Dr. Stephen Kemble is immediate past president of the Hawaii Medical Association.
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