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Saturday, October 18, 2014

Health Care Reform Articles - October 18, 2014

Unable to Meet the Deductible or the Doctor

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Patricia Wanderlich got insurance through the Affordable Care Act this year, and with good reason: She suffered a brain hemorrhage in 2011, spending weeks in a hospital intensive care unit, and has a second, smaller aneurysm that needs monitoring.
But her new plan has a $6,000 annual deductible, meaning that Ms. Wanderlich, who works part time at a landscaping company outside Chicago, has to pay for most of her medical services up to that amount. She is skipping this year’s brain scan and hoping for the best.
“To spend thousands of dollars just making sure it hasn’t grown?” said Ms. Wanderlich, 61. “I don’t have that money.”
About 7.3 million Americans are enrolled in private coverage through the Affordable Care Act marketplaces, and more than 80 percent qualified for federal subsidies to help with the cost of their monthly premiums. But many are still on the hook for deductibles that can top $5,000 for individuals and $10,000 for families — the trade-off, insurers say, for keeping premiums for the marketplace plans relatively low. The result is that some people — no firm data exists on how many — say they hesitate to use their new insurance because of the high out-of-pocket costs.
Insurers must cover certain preventive services, like immunizations, cholesterol checks and screening for breast and colon cancer, at no cost to the consumer if the provider is in their network. But for other services and items, like prescription drugs, marketplace customers often have to meet their deductible before insurance starts to help.
While high-deductible plans cover most of the costs of severe illnesses and lengthy hospital stays, protecting against catastrophic debt, those plans may compel people to forgo routine care that could prevent bigger, longer-term health issues, according to experts and research.

Largest Study of High-Deductible Health Plans Finds Substantial Cost Savings, but Less Preventive Care

FOR RELEASE
FridayMarch 25, 2011
The largest-ever assessment of high-deductible health plans finds that while such plans significantly cut health spending, they also prompt patients to cut back on preventive health care, according to a new RAND Corporation study. The findings are published in the March edition of the American Journal of Managed Care.
Studying more than 800,000 families from across the United States, researchers found that when people shifted into health insurance plans with high deductibles, their health spending dropped an average of 14 percent when compared to families in health plans with lower deductibles.
Health care spending also was lower among families enrolled in high-deductible plans that had moderate health savings accounts sponsored by employers. But when employer contributions to such savings accounts accounted for more than half of an individual's deductible, savings decreased among families enrolled in these so-called consumer-directed health plans.
However, over the same period, families that shifted to high-deductible plans significantly cut back on preventive health care such as childhood immunizations and cancer screenings.
"We discovered that costs go down dramatically during the first year people are enrolled in high-deductible health plans, as long as the deductible is at least $1,000 per person," said Amelia M. Haviland, a study co-author and a statistician at RAND, a nonprofit research organization. "But we also found concerning reductions in use of preventive care. This suggests people are cutting both necessary and unnecessary care."


Covered California becomes a prime target in Proposition 45 debate
By JON HEALEY
oposition 45 would extend the regulatory power that Proposition 103 gave the state Insurance Commissioner over property and casualty coverage to a new branch of the insurance market: the health policies sold to individuals and small groups. So it's no surprise that the Proposition 45 campaign would turn into a reprise of 1988's battle over Proposition 103, pitting the consumer advocates at Consumer Watchdog against big insurance companies.
What has been surprising is the degree to which the campaign has devolved into a fight between Consumer Watchdog and Covered California, the health insurance exchange the Legislature created to implement the 2010 federal healthcare reform law (better known as Obamacare).
The exchange hasn't taken a formal position on the ballot measure, other than to raise questions about how it would mesh with Covered California's efforts to negotiate rates with insurers. Some members of the exchange's board, however, have voiced concerns that the proposition could undermine its work. So has Peter V. Lee, the exchange's executive director.
In response, Consumer Watchdog and other proponents of the measure have trained much of their rhetorical fire on the exchange, arguing that it's been an ineffective negotiator and even a captive of the insurance industry. The attacks took a sharper turn Monday after the Associated Press reported that the exchange had awarded $184 million in no-bid contracts. Consumer Watchdog quickly dashed off a press release announcing that it had called on the state attorney general to investigate those contracts to determine "whether consultants have inappropriately used their position with the government agency to advance the interests of former and current insurance industry employers."
The release included a link to a chart highlighting the former insurance company executives who have been hired by Covered California as consultants or top employees.
Oh yeah, it's on.

A Prescription for Life’s Final Stretch

‘Being Mortal,’ by Atul Gawande


Atul Gawande’s “Being Mortal: Medicine and What Matters in the End” introduces its author as a myopically confident medical school student whose seminar in doctor-patient interaction spent an hour on Tolstoy’s novella “The Death of Ivan Ilyich.” As a young man, he was not ready to understand the title character’s loneliness, suffering and desire to be pitied. He saw medical compassion as a given and Ivan Ilyich’s condition as something modern medicine could probably cure. He and his fellow students cared about acquiring knowledge and competence. They did not see mortality as part of the medical equation.
Now a surgeon (and rightfully popular author) in his 40s, Dr. Gawande sees why that story was part of his training. “I never expected that among the most meaningful experiences I’d have as a doctor — and, really, as a human being — would come from helping others deal with what medicine cannot do as well as what it can,” he writes.
“Being Mortal” uses a clear, illuminating style to describe the medical facts and cases that have brought him to that understanding. He begins with an anecdote that illustrates how wrong doctors can be if they let their hubris and fear of straight talk meld with a patient’s blind determination to fight on, no matter what. “Don’t you give up on me,” demands a man with cancer, though the surgery he wants cannot possibly cure him. “He was pursuing little more than a fantasy at the risk of a prolonged and terrible death — which was precisely what he got,” Dr. Gawande writes.

When Doctors and Nurses Work Together

By 
 

Not long ago, I heard a respected senior colleague recount to a group of medical students and trainees the story of a patient who had died under his care some 15 years earlier. Afterward, he had spent hours talking with the family, trying, he said, “to be as kind to them as I possibly could.” The family had been grateful for all his efforts, but my colleague still struggled even to tell the story.
“Were you afraid of getting sued?” one of the students suddenly asked.
My colleague’s eyes widened, and he answered slowly, the tone of his voice shifting from grieving to professorial. “In medicine, malpractice isn’t something we just think about when a patient dies. Malpractice isalways in the back of your mind.”
The handful of senior doctors in the room nodded in grim agreement. Every one of us either had been named in or knew of a colleague embroiled in litigation. That evening we all urged the aspiring clinicians to be the best and most compassionate doctors they could be. We knew all too well how much easier it is simply to order more tests and procedures than necessary and to overtreat in hopes of avoiding a lawsuit.
But a study published earlier this year in the American Journal of Obstetrics and Gynecology has revealed that a group of doctors at Yale-New Haven Hospital has been quietly working to change the culture of “defensive medicine” that so many have come to accept as inevitable.
Beginning in 2003, the hospital’s department of obstetrics and gynecology, in collaboration with their malpractice insurance carrier, initiated a series of reforms to improve care. Those in charge had no illusions. Obstetrics was, and remains, one of the most legally embattled specialties, accounting for the highest proportion of malpractice payouts over $1 million. Their goal was only to make a small dent in adverse patient outcomes.

Big money, complex issues make Prop. 45 tough issue for state voters

by Marc Lifsher
Almost three decades ago, a small band of consumer activists persuaded California voters to slap tough new rate regulations on auto insurance.
Now that same group wants to crack down on health insurance rates.
And the insurance industry and its business allies are back with a multimillion-dollar war chest to fight Proposition 45 with an omnipresent media campaign.
The combination of big money and complex regulatory issues makes Proposition 45 a tough issue for voters, said Larry Levitt, a senior policy analyst at the nonprofit, nonpartisan Kaiser Family Foundation, unrelated to insurer Kaiser Permanente.
"You have interest groups lined up on both sides; all making a case that they are on the side of consumers," he said. "It's hard for voters to sort out who actually is on their side."
Proposition 45 would give California's elected insurance commissioner new powers to deny insurer requests for health insurance rate increases, if deemed excessive. Such veto power, which already exists in 35 other states, is similar to the commissioner's authority to deny auto and property insurance premium hikes given to the commissioner by voters in 1988 with passage of Proposition 103.
Health insurance, under current law, is regulated by two agencies, the Department of Insurance and the Department of Managed Health Care. Both agencies can review proposed rates but cannot deny them.
The initiative on the Nov. 4 ballot would apply only to about 6 million Californians who purchase their own health insurance or get it through a small employer. It doesn't apply to large employer plans or people on Medicare or Medi-Cal.
Proponents say Proposition 45 is the only logical way to keep the cost of individual health insurance in check. Opponents call the initiative an overreach that would give too much power to the insurance commissioner and create a complex and costly new bureaucracy.

Health care, property tax reform, education top gubernatorial contenders’ lists of No. 1 priorities

By Mario Moretto, BDN Staff
A newly elected governor will get at least one chance to make a bold statement of intent with his first legislative proposal in office, his “LD 1.”
That first initiative may not be the most remembered initiative or even the most impactful of a governor’s four-year term, given unforeseen incidents such as recessions or ice storms that can interrupt even the most well-crafted policy agendas. But it’s a bill loaded with symbolism, representing the No. 1 priority for an incoming executive with four years in the Blaine House ahead of him.
Perhaps not surprisingly, the three candidates for governor this year — incumbent Republican Gov. Paul LePage, Democratic U.S. Rep. Mike Michaud and independent Eliot Cutler — have drastically different plans for their first legislative act, each with varying likelihoods of making their way into law.
Michaud says his LD 1 would be the “unfinished business” of Medicaid expansion. In 2010, President Barack Obama’s signature health care reform law, the Affordable Care Act, opened federal coffers to states that expanded the Medicaid program to all residents with incomes lower than 138 percent of the federal poverty level, or about $16,000 per year for a childless, single adult.
Most projections indicate expansion would result in roughly 70,000 Mainers gaining access to Medicaid if the state accepted the expansion. The federal government would pay the full cost of expansion for most of the newly covered population through the end of 2016. After that, its share of the cost will drop, incrementally, to 90 percent.
“I want to make sure that Mainers can see a doctor when they’re sick, and I want to make sure that Maine can take full advantage of the federal law,” Michaud said in a written statement to the BDN.
Majority Democrats in the Legislature made expansion their top policy priority during the past two years, and passed five different bills to expand coverage. However, Republicans, led by LePage, resisted, saying the expansion would cost the state too much money. Democrats were not able to muster the support necessary to override LePage’s vetoes.
Michaud said expansion would have a near-immediate impact on the state. It would provide health insurance to low-income Mainers and create 3,000 additional jobs in the state’s health care industry, he said, citing White House figures. Michaud also said expansion would save hospitals hundreds of millions of dollars in bad debt and charity care.
Assuming the Democratic Party retains control of both chambers of the Legislature, expansion could feasibly be done in the early days of the first regular session under a Michaud administration. However, if Republicans regain control of the House or Senate, the effort may be doomed. While a handful of GOP lawmakers has supported expansion, the party as a whole has opposed it.


California spends $13.4 million to fix Obamacare service woes
By CHAD TERHUNE
October 17, 2014
lifornia's health insurance exchange hired two outside firms for $13.4 million to address long wait times for consumers calling about their Obamacare coverage.
Covered California said it will pay $9.8 million to Faneuil Inc. and $3.6 million to Maximus Inc. to add more call-center capacity during the next open enrollment season starting Nov. 15.
"We had call response times that were far too long," said Peter Lee, the exchange's executive director. "We were swamped."
Many consumers and insurance agents have complained about the exchange's shoddy customer service and long hold times. In August, the exchange answered 1% of calls within 30 seconds, far short of its 80% goal.
The average wait time was under five minutes Thursday, according to the exchange.
Lee said the exchange is nearly doubling its service-center staff to 1,300 to help more than 1 million Californians renew their health-law policies by Jan. 1. The first batch of renewal notices for 2015 went out this week.
The state said it has spent $22.6 million on improving the speed and reliability of its website and online enrollment.
Covered California said more than 200,000 people have signed up for Obamacare coverage since regular enrollment ended in April under the Affordable Care Act.
But in a sign of the churn in the individual insurance market, an additional 150,000 people dropped out of the exchange after getting health benefits at work or failing to pay their premium.
People who move, lose their employer coverage or have some other qualifying event in their life can enroll outside the normal sign-up period.
Overall, Covered California said it has 1.1 million people enrolled now, down from its previous tally of 1.2 million.
Part of that was because the exchange said 81% of enrollees paid their initial premium compared with its earlier estimate of 85%.
Opponents of the health law have criticized the federal and state exchanges for not disclosing detailed enrollment figures in a timely manner.
The exchange wants to close open enrollment in mid-February with 1.7 million people enrolled.

Commentary: Obamacare Helps Millions, but Per Capita Cost of Care Still Higher Than in Other Nations

Wednesday, 15 October 2014 00:00 By Wendell Potter, The Center for Public Integrity | Op-Ed
Although there is no shortage of critics of the Affordable Care Act — on the far left as well as the right — it’s hard to dispute that the law has benefited millions of Americans. And not just those who have become newly insured over the past year.
President Barack Obama cited some of the impressive statistics last Thursday, the day after the one-year anniversary of the turbulent debut of the Obamacare-created online health insurance exchanges.
"In just the last year, we’ve reduced the share of uninsured Americans by 26 percent," he said. "That means one in four uninsured Americans — about 10 million people — have gained the financial security of health insurance in less than one year."
Approximately 8 million people were finally able to sign up for coverage on the exchanges after the many technical problems were fixed. Many others were able to enroll in health plans on private exchanges or by working directly with an insurance company or agent. As a consequence, the rate of uninsured Americans dropped from 21 percent in September 2013 to 16.3 percent this past April.
Even though open enrollment for the Obamacare exchanges ended in April, people have still been joining the ranks of the insured since then. In fact, the Congressional Budget Office estimates that the number of newly insured Americans will grow to 12 million by the end of this year.
A significant percentage of those folks were not able to find affordable coverage in the past, and many were not able to buy health insurance at any price because of insurance industry business practices that were outlawed by the ACA. Before Obamacare, insurance companies were able to declare you “uninsurable” if you had a preexisting condition, even conditions you might have been born with.


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