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Tuesday, November 11, 2014

Health Care Reform Articles - November 11, 2014

Death by Typo

The Latest Frivolous Attack on Obamacare

My parents used to own a small house with a large backyard, in which my mother cultivated a beautiful garden. At some point, however — I don’t remember why — my father looked at the official deed defining their property, and received a shock. According to the text, the Krugman lot wasn’t a rough rectangle; it was a triangle more than a hundred feet long but only around a yard wide at the base.
On examination, it was clear what had happened: Whoever wrote down the lot’s description had somehow skipped a clause. And of course the town clerk fixed the language. After all, it would have been ludicrous and cruel to take away most of my parents’ property on the basis of sloppy drafting, when the drafters’ intention was perfectly clear.
But it now appears possible that the Supreme Court may be willing to deprive millions of Americans of health care on the basis of an equally obvious typo. And if you think this possibility has anything to do with serious legal reasoning, as opposed to rabid partisanship, I have a long, skinny, unbuildable piece of land you might want to buy.
Last week the court shocked many observers by saying that it was willing to hear a case claiming that the wording of one clause in the Affordable Care Act sets drastic limits on subsidies to Americans who buy health insurance. It’s a ridiculous claim; not only is it clear from everything else in the act that there was no intention to set such limits, you can ask the people who drafted the law what they intended, and it wasn’t what the plaintiffs claim. But the fact that the suit is ridiculous is no guarantee that it won’t succeed — not in an environment in which all too many Republican judges have made it clear that partisan loyalty trumps respect for the rule of law.

Estimate of Health Coverage Enrollment Leaves Room to Grow

By 

WASHINGTON — The Obama administration on Monday offered a surprisingly modest estimate of the number of people who would sign up for health insurance in the second round of open enrollment, which begins on Saturday.
Sylvia Mathews Burwell, the secretary of health and human services, said she was working on the assumption that a total of 9.1 million people would have such coverage at the end of next year.
By contrast, the Congressional Budget Office had estimated that 13 million people would be enrolled next year, with the total rising to 24 million in 2016. In the past, the White House has used the budget office numbers as a benchmark for success under the Affordable Care Act.
The new estimate appeared to be part of an effort by federal officials to lower public expectations, so the goal would be easier to meet and to surpass. In addition, the new number could indicate that administration officials believe it will be difficult to find and enroll many of the uninsured while retaining those who signed up in the last year.
“The number we are going to aim for this year is 9.1 million,” Ms. Burwell said on Monday during remarks at the Center for American Progress, a liberal research and advocacy group.
Ms. Burwell’s estimate was at the lower end of the range suggested by health policy experts in her department. In a report issued earlier Monday, the experts estimated that, at the end of next year, 9 million to 9.9 million people would have coverage purchased through insurance exchanges, or marketplaces.

Health Care Policy and Marketplace Review

Is the Administration Low-Balling Their 2015 Obamacare Enrollment Estimate?

Well, with an estimate of only 9 million to 9.9 million, apparently they are. But I will suggest the focus should not be on anybody's estimate for 2015 but rather on how many people need to enroll in Obamacare to make it sustainable.

A few points:
  • The Kaiser Family Foundation estimated that when Obamacare launched in 2014, 17.2 million people were eligible for subsidies.
  • The only place you can get an Obamacare subsidy is in the state and federal health insurance exchanges.
  • The longtime insurance industry underwriting rule is that you need 75% of an eligible group to be confident of a sustainable risk pool––that is enough healthy people paying in to offset the cost of the sick people.
  • So far 85% of those who have purchased health insurance in the exchanges are receiving a subsidy. 
  • The insurance company "3Rs" reinsurance program, that protects the carriers from most Obamacare underwriting losses, expires at the end of 2016. 
So, Obamacare needs to have a sustainable population participating by the time the insurance company support expires at the end of 2016.

While many more people will enroll off-exchange, the number of the subsidy eligible population enrolling is an easy number to get and, I will suggest, serves as a pretty good proxy for Obamacare's success.

It's a fairly easy calculation to figure out how many people we need in the Obamacare exchanges to be confident the program will be self-sustaining.

First, we need 75% of those 17.2 million who were subsidy eligible in the first place, or 12.9 million.

Presuming that 85% of those in the exchanges continue to be on subsidy, we would need a total of 15.2 million (12.9 million getting a subsidy and another 2.3 million not on subsidy) in order to reach a sustainable level.

Now, the 75% threshold is a guideline. Maybe the right number the exchanges need to hit is 14 million, or maybe it is 16 million. But this is the ballpark we need to be in.

The Congressional Budget Office (CBO) has estimated that 13 million will buy health insurance in the Obamacare exchanges by the end of 2015. To stay on a sustainable enrollment track, that 13 million estimate makes sense to me––leaving a net gain of only another 2 million in the third and final year of open enrollment.

Today, the administration said that their goal is for 9 million to 9.9 million to be purchasing health insurance on the exchanges by the end of 2015.

Is that a low-ball estimate designed to manage expectations?

Apparently. But playing expectation games is not what they need to be successful at.

Enrolling enough people for a sustainable insurance pool by the end of 2016 is what they will need.

If Obamacare isn't up to a sustainable enrollment level by the time the health insurance company reinsurance protections expire at the end of 2016, the 2017 rate increases will be huge.

Those 2016 rate increases will be released on about Election Day 2016.

Low-balling expectations might buy you some short-term media puff.

But if they don't get this thing to a sustainable enrollment level by November of 2016 no one will remember their latest PR campaign. 

Why Obamacare risks falling into a ‘death spiral’
by Dana Milbank-Washington Post
So it turns out there is an Obamacare death panel after all. 
It has nine members and it operates out of a marble building directly across the street from the Capitol.
When the Supreme Court on Friday announced that it would take up another challenge to the Affordable Care Act in March, it delivered the threat of two mortal blows to the signature achievement of the Obama presidency. 
First, it raised the possibility that the justices, who narrowly spared the law in 2012, will in June come out with a new ruling that would dismantle the law on different grounds. But even if the justices make no such ruling, the very act of taking up the challenge to the law will itself undermine the law. The justices announced their decision just a week before the open-enrollment period for 2015 begins — and the looming possibility that the high court will strike down the law will probably deter those who are considering signing up for its coverage.
Thus did Sylvia Mathews Burwell, the new secretary of health and human services, find herself in a defensive posture Monday afternoon, even though she was in the friendly environs of the liberal Center for American Progress. An event had been scheduled to generate enthusiasm for the new open-enrollment season, but the host, former Ohio governor Ted Strickland, had little choice but to acknowledge the elephant that John Roberts had led into the room.
“What do you want consumers to know and should they be concerned, as we head into this open-enrollment period, about this Supreme Court decision?” he asked gingerly.
Burwell’s practiced reply: Nothing to see here. 
“The most important thing for consumers to know is that nothing has changed,” she said, assuring all that the law’s tax credits would continue. “And so as we go into open enrollment, nothing has changed,” she repeated. She kept her face determinedly in a smile, though nothing about the gesture indicated pleasure.


Some patients are getting colonoscopies too often

By 

 | GLOBE STAFF   NOVEMBER 10, 2014
A colonoscopy is one of the most effective tests available to protect against a major cancer — a message heard by growing numbers of adults. But a recently published study revealed that some patients get the exam too often, exposing them to unneeded risks and raising costs.
The research, which looked at doctors and their patients in the Boston area, is part of a significant shift in how medical care is studied. Until recently, computerized medical records have been used mostly to study whether patients are failing to get important tests, such as mammograms to detect breast cancer and blood tests to check for high cholesterol.
But increasingly, providers are building more sophisticated electronic medical record systems that allow researchers to study when patients receive too many, rather than too few, medical procedures and tests.
Eliminating unnecessary care has become a major focus in American medicine. Since 2012 a consumer campaign called Choosing Wisely has created lists of 350 things doctors and patients should question, such as antibiotics for ear infections, CT scans for simple headaches, and too-frequent colonoscopies.
Patients get unneeded care for many reasons, including when doctors are not up-to-date on clinical research, providers have a financial incentive to give more treatment, and patients themselves push for certain tests.
The Choosing Wisely project helped prompt Dr. Thomas Sequist, chief quality and safety officer at Partners HealthCare, to look at whether patients at Harvard Vanguard Medical Associates, a large Massachusetts physicians’ group, were getting colonoscopies more often than necessary.


The Great Wage Slowdown, Looming Over Politics



A quiz: How does the Democratic Party plan to lift stagnant middle-class incomes?
I realize that liberal-leaning economists can give a long, substantive answer to this question, touching on health care costs, education and infrastructure. But most Americans would not be able to give a clear answer — which helps explain why the party took such a drubbing last week.
The Democratic Party’s short-term plan to help the middle class just isn’t very clear. Some of the policies that Democrats favor, such as broader access to good education, take years to pay off. Others, like reducing medical costs or building new roads, have an indirect, unnoticed effect on middle-class incomes.
The fact remains that incomes for most Americans aren’t growing very fast and haven’t been for years. Median inflation-adjusted income last year was still $2,100 lower than when President Obama took office in 2009 — and $3,600 lower than when President George W. Bush took office in 2001. That’s not just because of the financial crisis, either: Last month was another solid one for job growth and another weak one for average wage growth, the latest jobs report showed.
We’re living through the great wage slowdown of the 21st century, and nothing presents a larger threat to the Democrats’ electoral fortunes than that slowdown.
The Democratic Party fashions itself as the defender of working families, and low- and middle-income voters are indeed more favorably disposed to Democrats than to Republicans. Those voters have helped the party win the popular vote in five of the last six presidential elections. But if Democrats can’t deliver rising living standards, many voters aren’t going to remain loyal. They’ll skip voting or give a chance to Republicans who offer an alternative, even a vague alternative.
As the 2016 presidential campaign begins to stir, the central question will be how both parties respond to the great wage slowdown. Neither has offered a persuasive answer so far — let alone a solution — which is why the public mood is so sour and American politics has been so tumultuous lately. The partisan makeup of the Senate has seesawed more over the past decade than in any time since just after World War II. The Republicans won big victories in 2004, 2010 and 2014, the Democrats in 2006, 2008 and 2012.

Medicare Proposes Paying for Lung Cancer Screenings for Older Longtime Smokers

By 

WASHINGTON —  Medicare will cover annual screenings for lung cancer for older Americans with long histories of heavy smoking, the federal government said Monday in a proposal that would cover an estimated four million people, many of whom are at greatest risk for the disease.
Monday’s draft decision by the Centers for Medicare and Medicaid Services would extend coverage for CT scans to Medicare beneficiaries who smoked at least a pack a day for 30 years or the equivalent, even if they quit as long as 15 years ago. Scans would cost recipients nothing; the coverage would apply to beneficiaries through age 74.
The proposal follows a more sweeping recommendation last year by an influential government health panel that such smokers ages 55 to 80 get annual screenings, a policy shift that experts said had the potential to save 20,000 lives a year. That recommendation focused on current and former smokers at highest risk, a population of about 10 million Americans.
Under the Affordable Care Act, private insurers must cover such screenings. But the law was silent on whether Medicare had to do so. Monday’s proposal made it clear that high-risk Medicare recipients would be included.

Shortage of Medicaid Doctors? Not if You Ask Patients

One longstanding concern about Medicaid is that too few doctors will accept it, because it tends to pay providers less generously than private plans do. This concern shows up in news articles about Medicaid, driven by evidence from doctors’ offices. But if you ask Medicaid enrollees directly, they reveal that access to primary care is comparable to that for private plans.
A report from the inspector general at the Department of Health and Human Services released in late September reinforced concerns about access to care for Medicaid enrollees. As my colleague Robert Pear reported, the inspector general found wide variation across states in access standards. For instance, the maximum travel distance states allow varies from five to 60 miles; the maximum appointment wait times vary from one to 60 days; and the minimum provider density varies from one in 100 to one in 2,500 enrollees, among other standards.
Worse, the inspector general found that only eight of the 33 states it examined conducted tests to assess whether Medicaid patients’ access to care met their standards.
Access problems could be exacerbated by the Affordable Care Act, which extends Medicaid coverage to millions more Americans, and expands coverage through private plans. To at least partly address this concern, the law includes an increase in funding for primary care training and in Medicaid payments for primary care visits through this year, and Congress is considering extensions. In its waiver application to allow residents eligible for Medicaid to participate in its state exchange, Arkansas argued that higher payments to providers were necessary to encourage the supply of care to meet the new demand.
Medicaid enrollees may, in fact, have to work a bit harder to find a primary care doctor who will see them, but almost all are still able to find one. Using data from a large, nationally representative survey, Genevieve Kenney and colleagues did find that a substantial minority, 11 percent, of new Medicaid enrollees said that they had difficulty making an appointment. But only 2.8 percent said that they could not do so at all. To be sure, the program ideally would provide access for all its enrollees, but a 2.8 percent failure rate is probably a lot lower than most people think and suggests modest improvements may be sufficient to bring that number to zero.

Many Latinos shun Obamacare for fear of getting relatives deported
Lilian Saldana turned down Obamacare coverage once, and she might do it again.
With sign-ups set to resume Saturday, the 23-year-old Covina resident and her younger sister are hesitant to enroll because their parents are immigrants who are not citizens and therefore ineligible for benefits under the Affordable Care Act.
Saldana, an after-school tutor, admits she could put the insurance to good use for a checkup, but she worries about putting her parents at risk or creating a rift at home.
"We've always done things together as a family," she said.
The Saldana sisters are among roughly 600,000 Latinos in California who remain uninsured — despite qualifying for subsidized coverage under the federal health law. Latinos outnumber whites and Asians among the 1.3 million Californians who are eligible for federal aid and lack private health coverage.
California officials, sensing continued reluctance from people such as the Saldanas, are tackling the immigration fears directly for the first time in new TV ads. One commercial shows documents flying into a vault as a Latino man tells viewers their information is "confidential and private."
This is part of $95 million the Covered California exchange will be spending on marketing and outreach in the months ahead. California accounted for 15% of enrollment nationwide during the initial launch, and the Obama administration is counting on the Golden State to deliver another big turnout.

A rough ride for Mainers over the next four years of LePage

By Luisa Deprez and John Dorrer, Special to the BDN
Posted Nov. 11, 2014, at 8:02 a.m.
Gov. Paul LePage’s re-election victory is an affirmation from a growing share of Maine voters of his behavior and the policies he has pursued over the past four years. It also shows, once again, a deepening ideological divide in our state: Over 50 percent of Maine voters backed Mike Michaud and Eliot Cutler, who offered more progressive social and economic policies.
With a Republican state Senate, LePage will have more support in the Maine Legislature. We look cautiously to the next four years hoping the state and its residents can withstand the difficult months ahead with LePage back in the governor’s seat.
So, what will we have to look forward to?
On jobs and the economy, LePage’s campaign offered few ideas and proposals in spite of wrenching economic restructuring that is transforming Maine’s economy. There has been no clear economic development vision or strategy in the previous four years, and there will likely not be one during the last term. Instead, his emphasis will likely remain on relaxing regulations and encouraging business attraction and expansion through tax reduction incentives, loans and subsidies. These are tired formulas with few measurable results.
In spite of four years of an improving national economy, pro-business policies from the LePage administration and income tax reductions, Maine’s economy has failed to ignite optimism. We have failed to recover all jobs lost during the recession, experienced anemic growth, and we continue to lag in national business climate rankings.
Maine’s slow population growth and older population will accelerate the aging of the workforce. There has been an absence of proactive strategy and policy proposals to address Maine’s workforce challenges from LePage. Failure to address workforce challenges can seriously impede economic growth in the next four years.
The health and well-being of Maine’s population will become even more critical as we age and relegate more families to low incomes. We expect to see continued vetoes of Medicaid expansion — if it passes in the first place — leaving 70,000 Maine residents without access to affordable health care. The state will continue to lose over $1 million per day in federal money through this continued rejection, and more in Maine will continue to have their health placed in jeopardy.
Also on health care, LePage has said he would continue to seek expanded primary health care access for the state’s numerous underserved rural areas. And he has promised to explore new avenues for expanding elderly housing.
In an otherwise contentious policy environment, there is widespread agreement that education continues to be the way out of poverty. But we wouldn’t be surprised to see state allocations for education taper off, as LePage has said that state funding for K-12 education is adequate. His administration’s school grading system will undoubtedly continue despite its consequential outcomes and lack of a plan to bolster under-performing schools. Maine will likely see additional charter schools.
As for higher education, the funding issue has largely been met with silence from LePage. He has said only that Maine needs to create a workforce that attracts businesses.

Anthem Joins With EMHS in Effort to Improve Health Care in Maine

Maine has a new Accountable Care Organization, and it's the largest commercial ACO in the state.  Anthem insurance and Eastern Maine Health Systems Beacon Health say the goal is to lower costs and improve healthcare for about 40,000 Anthem members.  While there are some potential financial risks for providers, EMHS and Anthem say patients have everything to gain.
Patty Wight reports on the establishment of the largest commercial Accountable Care Organization in Maine.
It's the Affordable Care Act that created Accountable Care Organizations, or ACOs. The idea behind them is to tie health care reimbursements to overall patient quality, versus itemized procedures or services.  Doctors and hospitals band together to coordinate patient care, and they're rewarded financially when that care is of high quality, and efficient.  
This ACO between EMHS Beacon Health and Anthem includes 15 hospitals and 400 primary care providers across 67 Maine cities and towns. EMHS's Vice President of Network Development Mike Donahue says his organization has committed to hold the cost for health services flat while improving outcomes.
"Essentially this is a one-year arrangement that we hope to transition into a multi-year arrangement," Donahue says.
For its part, Anthem will provide some money upfront to providers to invest in improving care - things like hiring nurse care coordinators to call patients in between visits to make sure they're taking medications and meeting their health goals.  
Anthem already does this under its Enhanced Personal Care Program for about half of the primary care providers in the state.  The addition of the EMHS ACO brings that number to about 75 percent.  Spokesman Rory Sheehan says Anthem also shares data with physicians.
"This helps them identify gaps in care, and whether a patient is taking the medication they're supposed to be taking," Sheehan says. So basically, in a way, we're able to help complete the full picture for physicians with some of the data we have available to us."

Insurer reform on doctor reimbursements benefits patient care

BY JOE LAWLOR STAFF WRITER
Anthem Blue Cross and Blue Shield’s announcement Monday that it is expanding its “accountable care organization” network to Bangor is the latest example of insurance companies enacting payment reforms that will change the way family doctors are reimbursed and how they care for patients, health experts say.
The changes will eventually improve efficiency in the primary care system by reducing duplication of medical services, overuse of medical devices and unnecessary trips to the emergency room, said Mitchell Stein, a Cumberland-based health policy analyst.
Stein said that should result in lower costs for everyone – patients, doctors and insurance companies.
“Pretty much everyone across the country is trying to do similar things, although there’s all these different iterations on how it’s going to change,” Stein said.
In a nutshell, insurance companies are moving away from reimbursing doctors for specific services – such as paying a fee every time a piece of medical equipment is used – and toward creating financial incentives for doctors to improve the overall wellness of their patients.
“Fee-for-service tends to be inefficient and puts the focus on volume, which doesn’t work well for patients and preventive care,” said Kevin Lewis, CEO of Maine Community Health Options, a Lewiston-based insurance co-op that implemented similar payment reforms when it began doing business in 2013.
Instead of reimbursing based on volume of patient visits and procedures, insurance companies are reimbursing more for patient outcomes, such as avoiding unnecessary emergency room trips.


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