Pages

Tuesday, August 19, 2014

Health Care Reform Articles - August 19, 2014

Due to August schedules, this blog is playing a little bit of catch-up. So it's a bit longer than usual. Because of my upcoming travel schedule, this blog will be a little more infrequent than usual, so take your time perusing this one.

-SPC


The costs of complexity in health reform just keep rising

By Dr. Philip Caper, Special to the BDN
Posted Aug. 14, 2014, at 11:18 a.m.
As I’ve written before, the costs of unnecessary complexity in health care reform are very high, and they are rising. There are at least three recent examples.
One is the flap over whether people who have received health insurance through the exchanges run by the federal government are eligible to receive government subsidies, as they have been led to believe. Courts have disagreed on this point, opening the door for yet one more food fight about the legality of portions of the Affordable Care Act.
Complex federal legislation, inevitably the product of many authors, is usually full of many minor (and some major) errors. These errors are usually corrected during the process of reconciling the differing House and Senate versions during the “conference committee” process.
Because of the divisive politics leading up to the passage of the ACA, no such committee was ever convened.The House of Representatives simply passed the Senate bill without changes — errors and all — eliminating the need for a House-Senate conference.
One of those errors was the granting of explicit authority for the exchanges run by the states, but not the federal government, to provide subsidies to people they enrolled, even though any common-sense interpretation would conclude that congressional intent was to give all exchanges, whether state or federal, such authority.
Nevertheless, that omission provided an exploitation opportunity to those looking for an excuse to sabotage the entire law. And exploit it they have, bringing a lawsuit that could end up in the Supreme Court. The costs of the ACA in dollars and confusion have risen as a result.
Another example is the (on its face) ridiculous attempt to sue President Barack Obama for failing to enforce with enough enthusiasm a provision of the law requiring some employers to offer health insurance to their employees or pay a fine. This puts Republicans in the interesting position of threatening to sue Obama for failing to vigorously enforce a law they have repeatedly tried to repeal.
Additionally, billions of dollars have been spent unsuccessfully trying to construct exchanges that comply with the complicated federal requirements imposed by the ACA in an attempt to perfect a marketplace for private insurance. Even some states (such as Massachusetts) where exchanges created pre-Obamacare were already working have experienced chaos, and because of it have thrown tons of their own and federal dollars down a rathole.
These are just a few examples of your tax (and health care) dollars at work. Even though these complexities provide full employment for thousands of lawyers, consultants, navigators and other helpers, they don’t buy even one Band-Aid’s worth of health care.
The real tragedy here is that if the “policymakers” in Washington were really interested in serving the needs of most of their constituents instead of those of their corporate contributors, all of this expense and confusion could have been avoided. Perhaps instead spent on providing care to the millions who will be left out, even after Obamacare is fully implemented.
The sole purpose of the exchanges is to provide a choice of insurance companies. But the fact is that most people don’t give a hoot about who their insurance carrier is. What they do care about is who their health care provider is. In yet another unintended consequence of this complex law, many insurance companies are doing their best to limit that choice in order to save themselves money.
Ironically, it is actually cheaper to cover everybody than it is to spend all of the unnecessary time, money and effort collecting the information needed to slice and dice people into smaller and smaller risk pools so we can then decide which of them “deserve” health care. Moreover, risk pools of different types of people (old/young, wealthy/poor, employed/not employed, well/sick) create yet another opportunity for politicians to play us off, one against the other.

 The Latest Obamacare "Glitch" Isn't a Glitch At All—and It's Democrats' Fault
By 
he most important thing the Affordable Care Act does is create a health coverage guarantee for all Americans. By the time the ACA passed, all other advanced countries around the world had already established similar guarantees. But most of them did so pretty straightforwardly: by taxing citizens and then paying their medical bills. Obamacare, by contrast, establishes the guarantee by fiat, and then makes it a sustainable promise by compelling people to purchase one of many private insurance options using carrots (subsidies) and sticks (the penalty for lacking coverage).
Needless to say, this is a much more complex system than single payer. But it was the system Democrats settled upon, in part because it was theoretically less disruptive to existing insurance systems than other reforms, and in part because they mistakenly took Republicans at their word that it was the kind of universal health care system they would support. Massive industry opposition to single payer played a big role, too.
The system is working today. But, as we’re about to see—and as many liberals warned—there are inherent problems with its architecture, beyond the fact that most people don’t equate guaranteed health care with being required to buy insurance from Aetna or one of its competitors.
If you enrolled in a health plan through an Obamacare exchange in the past 10 months, you could be forgiven for assuming that your work was mostly done—that if your income didn’t rise significantly, and you were satisfied with your plan, you were good to go until, say, your employment or marital status changed.
But you actually have to re-enroll every year. And there’s no guarantee that a) your existing plan will still be available, b) its premiums won’t increase, or c) the government’s contribution to your premium won’t fall.

Pittsburgh Health Care Giants Take Fight To Each Other's Turf

By 
Pittsburgh's dominant health insurance company and its largest healthcare provider are, essentially, getting a divorce.
For decades, Highmark Blue Cross/Blue Shield and University of Pittsburgh Medical Center worked together. But as the line between insurance companies and health care providers across the country blurs, these longtime allies are venturing into each other's business and becoming competitors.
In the process, patients can get caught in the middle. Day-care worker Gail Jameson has Highmark insurance and she's been going to the same UPMC medical office for more than 20 years. "I could go in and just stop in if I needed to because it's close to my work," Jameson says. "I go past it every day."
She's about five years from retirement and was disappointed to learn her Highmark policy will no longer include UPMC providers. She has to find all new doctors through another health system that is unfamiliar to her.
The road to divorce began when insurer Highmark got into the hospital business. It bought the struggling West Penn Allegheny Health System, which was UPMC's main competitor.
"Highmark stepped in in order to ensure that there was competition in the marketplace and there would continue to be consumer choice," says Highmark President and CEO David Holmberg. In a town where UPMC controls more than 60 percent of the market, Holmberg says there needs to be healthier competition among providers.
There's another reason an insurance company would decide to become a healthcare provider: the Affordable Care Act. It tells insurance companies what basic services to offer; who they must insure and even what percent of premiums can go to administrative expenses and profits. That takes away a lot of what insurance companies used to do, so they're looking for new reasons to exist.
"Insurers are trying to demonstrate that they bring value to the table and are doing more than just brokering a benefit ... and doing more than paying bills," says Gail Wilensky, senior fellow at Project HOPE.
Wilensky says some insurance companies are responding by building more efficient networks of high-quality providers. Highmark went a step beyond that and became a provider of health care itself.
UPMC responded by expanding its existing insurance business and refusing to sign a new long-term contract with Highmark, saying it could not both compete and work with Highmark.
"We couldn't have a contract with them," says UPMC President and CEO Jeffrey Romoff, "Because they [Highmark] have the burden of keeping their provider side alive. So, for every one of their insurance subscribers they will want to steer them to go to their own providers."
The divorce of Highmark from UPMC is all but final now. An agreement between the two companies will expire on January 1, 2015. The state of Pennsylvania negotiated atransition agreement. It does things like ensure Highmark subscribers already in certain kinds of treatment at UPMC can continue receiving care.
Now the Pittsburgh health care landscape looks very different. "It went from one of the least competitive environments that you can imagine — a dominant insurer and a dominant health system joined at the hips with a long term contract," says Romoff, "To one without a long-term contract with, now, five choices."

Medicare Advantage Is More Expensive, but It May Be Worth It

Medicare Advantage plans — private plans that serve as alternatives to the traditional, public program for those that qualify for it — underperform traditional Medicare in one respect: They cost 6 percent more.
But they outperform traditional Medicare in another way: They offer higher quality. That’s according to research summarized recently by the Harvard health economists Joseph Newhouse and Thomas McGuire, and it raises a difficult question: Is the extra quality worth the extra cost?
It used to be easier to assess the value of Medicare Advantage. In the early 2000s, Medicare Advantage plans also cost taxpayers more than traditional Medicare. It also seemed that they provided poorer quality, making the case against Medicare Advantage easy. It was a bad deal.
At that time, Medicare beneficiaries could switch between a Medicare Advantage plan and traditional Medicare each month. (Now, beneficiaries are generally locked into choices for all or most of a year.) In that setting, the Medicare Payment Advisory Commission (MedPAC) found that relatively healthier beneficiaries were switching into Medicare Advantage and relatively sicker ones were switching out.
This suggested that Medicare Advantage didn’t provide the type of coverage or the access to services that unhealthier beneficiaries wanted or needed. Since the point of insurance is to pay for needed care when one is sick, it was tempting to condemn the program as having poor quality and failing to fulfill a basic requirement of coverage.
But things have changed. Mr. Newhouse and Mr. McGuire show, for example, that by 2006-2007, health differences between beneficiaries in Medicare Advantage and those in traditional Medicare had narrowed. About the same proportion of beneficiaries in Medicare Advantage as in traditional Medicare rated their health as fair or poor. This suggests that sicker beneficiaries were not switching out of Medicare Advantage and healthier ones were not switching in to the extent they had been in earlier years.
Also, in contrast to studies in the 1990s, more recent work finds that Medicare Advantage is superior to traditional Medicare on a variety of quality measures. For example, according to a paper in Health Affairs byJohn Ayanian and colleagues, women enrolled in a Medicare Advantage H.M.O. are more likely to receive mammography screenings; those with diabetes are more likely to receive blood sugar testing and retinal exams; and those with diabetes or cardiovascular disease are more likely to receive cholesterol testing.
http://www.nytimes.com/2014/08/19/upshot/medicare-advantage-is-more-expensive-but-it-may-be-worth-it.html?smid=nytcore-ipad-share&smprod=nytcore-ipad&abt=0002&abg=1

Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients

By 
WASHINGTON — In a policy change, the Obama administration is planning to pay doctors to coordinate the care of Medicarebeneficiaries, amid growing evidence that patients with chronic illnesses suffer from disjointed, fragmented care.
Although doctors have often performed such work between office visits by patients, they have historically not been paid for it.
Starting in January, Medicare will pay monthly fees to doctors who manage care for patients with two or more chronic conditions like heart disease, diabetes and depression.
“Paying separately for chronic care management services is a significant policy change,” said Marilyn B. Tavenner, the administrator of the Centers for Medicare and Medicaid Services. Officials said such care coordination could pay for itself by keeping patients healthier and out of hospitals.
With the new initiative, Medicare will adopt some of the techniques devised by health maintenance organizations to manage the care of their patients. About 30 percent of the 54 million Medicare beneficiaries are in H.M.O.s and other private health plans run by companies like Kaiser Permanente and Humana, but 70 percent are still in the traditional fee-for-service Medicare program.
Doctors will draft and help carry out a comprehensive plan of care for each patient who signs up for one. Under federal rules, these patients will have access to doctors or other health care providers on a doctor’s staff 24 hours a day and seven days a week to deal with “urgent chronic care needs.”
The Obama administration rejected pleas from doctors to relax or delay “the 24/7 requirement,” saying it was essential.

The following article could apply equally to health care.
-SPC

Teaching Is Not a Business

By DAVID L. KIRP
TODAY’S education reformers believe that schools are broken and that business can supply the remedy. Some place their faith in the idea of competition. Others embrace disruptive innovation, mainly through online learning. Both camps share the belief that the solution resides in the impersonal, whether it’s the invisible hand of the market or the transformative power of technology.
Neither strategy has lived up to its hype, and with good reason. It’s impossible to improve education by doing an end run around inherently complicated and messy human relationships. All youngsters need to believe that they have a stake in the future, a goal worth striving for, if they’re going to make it in school. They need a champion, someone who believes in them, and that’s where teachers enter the picture. The most effective approaches foster bonds of caring between teachers and their students.
Marketplace mantras dominate policy discussions. High-stakes reading and math tests are treated as the single metric of success, the counterpart to the business bottom line. Teachers whose students do poorly on those tests get pink slips, while those whose students excel receive merit pay, much as businesses pay bonuses to their star performers and fire the laggards. Just as companies shut stores that aren’t meeting their sales quotas, opening new ones in more promising territory, failing schools are closed and so-called turnaround model schools, with new teachers and administrators, take their place.
This approach might sound plausible in a think tank, but in practice it has been a flop. Firing teachers, rather than giving them the coaching they need, undermines morale. In some cases it may well discourage undergraduates from pursuing careers in teaching, and with a looming teacher shortage as baby boomers retire, that’s a recipe for disaster. Merit pay invites rivalries among teachers, when what’s needed is collaboration. Closing schools treats everyone there as guilty of causing low test scores, ignoring the difficult lives of the children in these schools — “no excuses,” say the reformers, as if poverty were an excuse.

Hundreds of thousands could lose health insurance

WASHINGTON — Some 310,000 people with inconsistencies in their citizenship and immigration materials might lose their federal marketplace health coverage Sept. 30 unless they provide proper supporting documents by Sept. 5, the Obama administration announced Tuesday.
In May, the Department of Health and Human Services began contacting about 2 million people about discrepancies or errors in the personal information they’d provided in their insurance applications.
The problems stem, in part, from an administration policy that allowed applicants to self-report information about their incomes, citizenship and household size, all of which contribute to determining their eligibility for tax credits to help pay for coverage.
The self-reporting system was adopted because the federal marketplace technology to verify all applicant information wasn’t fully functional. For the first year of operation, the federal exchange used a scientific sampling process to weed out applications that understated household income.
About 970,000 people had information about their citizenship or immigration status on their applications that didn’t match data in government records.
The department has resolved the inconsistencies for about 450,000 people and is working on another 210,000. On Tuesday, HHS sent letters to roughly 310,000 others with citizenship or immigration matching errors who haven’t yet responded to previous attempts to resolve the matters.
The final notices, in English and Spanish, remind recipients they must provide proper documents by Sept. 5 or risk losing their coverage at the end of next month.


1,200 Maine consumers could lose Obamacare coverage for failure to prove legal residency

By Jackie Farwell, BDN Staff
Posted Aug. 13, 2014, at 1:02 p.m.
About 1,200 Maine consumers who signed up for insurance through Healthcare.gov failed to submit proof that they legally reside in the U.S., putting their coverage at risk, the federal Department of Health and Human Services announced Wednesday.
The Maine consumers were among 310,000 nationally identified with “inconsistencies” in their applications. U.S. HHS issued notices to the affected consumers this week warning that the federal government would terminate their coverage by Sept. 30 unless the missing citizenship and immigration documents are provided by Sept. 5.
“There have been a number of barriers for immigrants lawfully here who try to apply for insurance in the marketplace,” said Robyn Merrill, a senior policy analyst at Maine Equal Justice Partners. “They’re eligible for insurance.”
The Affordable Care Act prohibits undocumented workers from buying coverage through the health insurance marketplaces. Immigrants with green cards, refugees, individuals with student or worker visas, among others, are eligible for coverage.
Officials from President Barack Obama’s administration said they have already attempted to contact the affected consumers — who submitted incomplete information or documentation federal programs couldn’t verify — numerous times by mail, email and phone.
While their applications remain incomplete, an inconsistency doesn’t mean an individual is ineligible for coverage, federal officials said. So far, Maine consumers have retained their health insurance, according to Merrill.
Without the proper documentation, individuals will lose both their coverage and federal financial assistance to reduce the cost of their insurance. Most can’t afford the coverage without it, Merrill said.
A number of individuals already responded to the federal government, but their documentation was misplaced or lost, she said.
Further complicating the situation, this week’s notice was issued in English and Spanish, so many consumers may struggle to understand their application status, Merrill said.
Many of Maine’s newest immigrants hail from central and West African countries.
“People getting this notice in English is going to lead to a lot of confusion,” she said.
The Obama administration initially started in May with a roster of 970,000 individuals who signed up for coverage but had citizenship- or immigration-related inconsistencies in their applications. As of this week, 450,000 have submitted the required information, and another 210,000 remain in progress, according to HHS.

Hospitals reassess charity as Obamacare options become available

By Julie Appleby August 16
As more Americans gain insurance under the federal health law, hospitals are rethinking their charity programs, with some scaling back help for those who could have signed up for coverage but didn’t.
The move is prompted by concerns that offering free or discounted care to low-income, uninsured patients might dissuade them from getting government-subsidized coverage. It also reflects hospitals’ strong financial interest in having more patients covered by insurance as the federal government makes big cuts in funding for uncompensated care.
If a patient is eligible to purchase subsidized coverage through the law’s online marketplaces but doesn’t sign up, should hospitals “provide charity care on the same level of generosity as they were previously?” asks Peter Cunningham, a health policy expert at Virginia Commonwealth University.
Most hospitals are still wrestling with that question, but a few have changed their programs, Cunningham says.
The online charity care policy at Southern New Hampshire Medical Center in Nashua, for example, now states that “applicants who refuse to purchase federally-mandated health insurance when they are eligible to do so will not be awarded charitable care.”
The same rule disqualifies aid to those who refuse to apply for expanded Medicaid, which New Hampshire lawmakers voted to extend, beginning Aug. 15.
At BJC HealthCare, which has 12 hospitals in Illinois and Missouri, including Barnes Jewish Hospital in St. Louis, anyone receiving financial assistance must make some contribution to their care, for instance, $100 for emergency care. BJC does not bar financial aid to those who have refused to buy insurance through the health care law.

Hospital executives received big raises

Cost-cutting measures have little impact on pay

By Priyanka Dayal McCluskey

The departing chief of UMass Memorial Health Care in Worcester earned $4.8 million in 2012, topping the list of Massachusetts hospital executives who received healthy increases in seven-figure pay packages — even as they faced growing pressure to bring costs under control.
John G. O’Brien, who retired in February 2013 after more than a decade at UMass Memorial, nearly doubled his compensation from 2011, when he earned $2.4 million as head of the biggest health care system in Central Massachusetts. Much of his 2012 compensation included retirement benefits earned during his tenure.
O’Brien’s payout came several months before UMass Memorial reported a staggering $55 million operating loss for the fiscal year ending September 2013. The system has since laid off hundreds of workers and made other changes to close the gap under the new chief, Dr. Eric W. Dickson.
Douglas Brown, UMass Memorial’s chief legal counsel, said O’Brien helped expand the health system and did “a remarkable job” as chief executive.
“It is true we suffered a lot in 2013,” Brown said. “We certainly don’t blame that on John O’Brien. We look at his [entire] tenure.”
Brown added that the health system, which employs 12,000 and collects $2.5 billion in revenues, needs to pay well to attract top talent. “We want to pay competitively with the markets so that we can get the best,” he said.
Massachusetts nonprofits are required to report executive compensation and other figures to the attorney general’s office and the Internal Revenue Service each year, although there is a lag of more than a year in the reporting. Nine nonprofit hospital systems provided those documents to the Globe on Friday.
Most of the 11 top executives at these nonprofit systems received raises. The increases are consistent with a national trend of growing compensation for executives, even as state and federal laws push them to get rising costs under control. Massachusetts, known for its top-quality hospitals, has the highest health costs in the nation.

California's Medi-Cal explosion
By ANNA GORMAN
California is coming face to face with the reality of one of its biggest Obamacare successes: the explosion in Medi-Cal enrollment.
The numbers — 2.2 million enrollees since January — surprised healthcare experts and created unforeseen challenges for state officials. Altogether, there are now about 11 million Medi-Cal beneficiaries, constituting nearly 30% of the state's population.
That has pushed the public insurance program into the spotlight, after nearly 50 years as a quiet mainstay of the state's healthcare system, and it has raised concerns about California's ability to meet the increased demand for healthcare.
Even as sign-ups continue, state health officials are struggling to figure out how to serve a staggering number of Medi-Cal beneficiaries while also improving their health and keeping costs down. Many are chronically ill and have gone without insurance or regular care for years, and some new enrollees have higher expectations than in the past.
Medi-Cal is the largest version of the nation's Medicaid program for low-income and disabled people. Created as an anti-poverty program in 1965, Medicaid for years primarily served families, seniors and people with disabilities. Now, in the states that chose to expand their programs, the coverage is available to single adults without children and to those who make slightly higher incomes.
Real questions remain, however, about whether California is up to the task of covering so many more people, and about whether it has the healthcare infrastructure to handle the needs of the new enrollees. And the costs to the state will be significant.
Under the Affordable Care Act, the federal government pays 100% of the costs for newly eligible Medi-Cal enrollees for the first three years. But the state is responsible for 50% of the costs for those who qualified for the program before the Obamacare expansion, even if they hadn't previously enrolled. Publicity and outreach about the healthcare law brought hundreds of thousands of people forward who were previously eligible but hadn't signed up.

For healthier hospitals and Maine, LePage should have listened

Readers of a certain age likely remember a television ad about an investment company that supposedly was so good that, when people heard its name, they quieted down and leaned in to try to hear its advice. Following the hush on airplanes and in restaurants, the ad’s tag line was delivered: “When E.F. Hutton talks, people listen.”
If you sit a bunch of government officials around a table, you’ll find that they disagree about many things but they all listen to someone: bond ratings agencies. Whether elected or appointed, they want a good bond rating for their town, city, county, state or nation. Strong bond ratings translate into lower interest rates and save money. They also listen to what ratings agencies say about key business and the economy as a whole.
But somehow Medicaid expansion opponents are ignoring a new report from one of the big three ratings agencies.
Fitch Ratings made it clear that the majority of states that expanded Medicaid under the Affordable Care Act made the right move.
Just over half the states expanded Medicaid, including ones run by conservative Republican governors in Arizona, Idaho and Ohio. Center-right Gov. Chris Christie of New Jersey, who came to Maine to campaign for Gov. Paul LePage and who has been traveling around the country to raise his profile for a presidential bid, also expanded Medicaid.

Many Big Employers Plan To Offer Skimpy Health Options Despite Law

Nearly 1 in 6 companies plans to offer health coverage that doesn't meet the Affordable Care Act's requirements for value and affordability, a national survey of employers finds.
Many thought such skimpy coverage would be history once the health law was fully implemented this year. Instead, 16 percent of large employers in a survey released Wednesday by the National Business Group on Health said they will offer in 2015 these so-called skinny plans along with at least one insurance option that does qualify under ACA standards.
The results weren't entirely unexpected. Last year, it became clear that ACA regulations would allow skinny plans and even make them attractive for some employers. But this survey gives one of the first looks at how many companies followed through.
"It is a little higher than I would have expected but does not surprise me," says Timothy Jost, a law professor who specializes in consumer health at Washington and Lee University in Virginia. "It would be interesting to know what sectors of the economy these employers are in." Low-benefit plans traditionally have been offered by hotels, restaurant chains and other lower-wage industries, Jost said, "but this may be spreading."
The survey compiled responses from 136 large employers but didn't specify which industries made up the 16 percent offering low-benefit plans.
"My guess is that they are probably in those industries with low-wage employees where they have historically not been attracted to taking a lot of their paycheck for coverage and wanted something smaller," said Steve Wojcik, vice president of public policy at the National Business Group on Health.
Skinny plans are part of a two-step strategy that lets workers and employers avoid health law penalties but may not produce substantial coverage. Some skinny plans cover preventive care and nothing else — no inpatient or outpatient hospital treatment, says Edward Fensholt, a benefits lawyer with Lockton Cos., a large insurance brokerage and consulting firm.


Mass. sticking with its health insurance website

By Felice J. Freyer

Massachusetts will run its own health insurance exchange and won’t need to join the federal HealthCare.gov website, state officials announced Friday.
A software system adapted for Massachusetts by the tech firm hCentive passed muster with the US Centers for Medicare & Medicaid Services in a test late Thursday, giving officials confidence that it will be ready when enrollment for next year starts on Nov. 15.
The decision marks an important step toward recovery from the embarrassing failure of the Massachusetts Health Connector’s refurbished website, launched last October.
“Massachusetts will remain a state-based marketplace,” Maydad Cohen, special adviser to the governor who is overseeing the project, said in a conference call with reporters Friday morning. “We’ve successfully demonstrated hCentive’s ability to deliver a smooth consumer experience.”
Significantly, that includes integrating the state’s unique subsidy program along with the federal tax credits, which reduce premiums. The federal exchange could not have incorporated the state subsidies.
Since the spring, the Connector had been following a “dual track” — working with hCentive, a Virginia company, to develop its own software while simultaneously preparing to join the federal website if that first option failed. Now, the state has halted preparations for HealthCare.gov.
In Thursday’s test, hCentive demonstrated that its software could handle the application process for complex family situations, and communicate with health insurers.
But, Cohen added, “I can’t breathe a sigh of relief right now. Nobody can.” He said any technology project can encounter problems leading to delays — but this one has a firm start date of Nov. 15. Starting on that date, he expects 450,000 people to enroll in insurance plans that take effect Jan. 1.


Posted by at

No comments:

Post a Comment

Subscribe to: Post Comments (Atom)