Physicians For a National Health Care Plan
Medicare Payment Advisory Commission (MedPAC) Public Meeting, March 6, 2014
>From the transcript:
DR. [JULIE] SOMERS: Good afternoon. In this session, [Medpac staff] Kevin [Hayes], Katelyn [Smalley], and I would like to explore with you the idea of creating a per-beneficiary payment for primary care practitioners in the fee-for-service Medicare program. [p. 239]
…. [T]he Commission recommended establishing a medical home pilot [in 2008]. Variants of the recommendations for a primary care bonus and a medical home pilot were established under PPACA. … The [primary care bonus] program expires at the end of 2015, so we’d … like to hear the Commission’s views about extending the current program or replacing it with a per-beneficiary payment for primary care. [p. 240]
MR. [GLENN] HACKBARTH [MEDPAC CHAIR]: Okay. …. I am the one to blame if you don’t like this topic. I’m the instigator behind this, and I wanted just to say why that is. Why take this up now when there [are] … a number of medical home demonstration projects underway, some of which include Medicare? …. Why not just wait for the end of the medical home demonstrations?
There are two reasons for that. First … is the existing primary care bonus expires at the end of 2015…. Do we want to continue the existing bonus, or do we want to reconfigure it and do something like this?….
The second reason … is that I’ve become increasingly concerned about the medical home demonstrations on a number of different grounds. First of all, I am a little bit worried that the medical home model has … become gold-plated, and that in order to meet all of the NCQA requirements, et cetera, there are a lot of bells and whistles that have been added to it…. [M]y impression is that not all of them have really been validated as adding value, but they add cost, and so I’m worried that maybe the medical home model has a real cost disadvantage…. [pp. 251-253]
If you endorse a vague plan based on conventional wisdom rather than evidence and it doesn’t work, how do you revise it? Upon what evidence, by what logic, do you alter this or that part of the plan? The Medicare Payment Advisory Commission (Medpac) struggled with that problem at its March 6 meeting in the course of reviewing the performance of the “patient-centered medical home” (PCMH), an amorphous concept Medpac endorsed in 2008. The struggle did not go well. Commissioner after commissioner raised serious questions about the PCMH, but none of their questions triggered a productive discussion, the rationale for Medpac’s 2008 endorsement of the PCMH was never mentioned much less reviewed, and when the meeting was over it was impossible to say whether or how Medpac will propose changing the definition of the PCMH.
Revisiting the PCMH concept was Chairman Glenn Hackbarth’s idea. Hackbarth explained to his fellow commissioners that he wanted the commission to consider yet another PCMH experiment because a temporary bonus for Medicare primary care doctors, authorized by the Affordable Care Act, is due to expire at the end of 2015. (The bonus is measured as a percent of each claim submitted by primary care doctors for Medicare patients.)
Mr. Hackbarth posed three questions to his fellow commissioners:
(1) Is it a good idea to extend the bonus beyond 2015?
(2) If so, should Medpac recommend that the bonus be extended as is or should the bonus be converted to a per-patient-per-year (capitation) payment?
(3) If the commission recommends converting the bonus to a capitation payment, should doctors be required to meet all the requirements of a “patient-centered medical home” (PCMH) established by the National Committee for Quality Assurance (NCQA)?
Commission members seemed unanimously to support extending the bonus, and 13 of the 17 commissioners expressed support for converting the bonus to “home” payments. But not a single commissioner offered an answer to Hackbarth’s third question – what requirements, if any, in the current definition of the PCMH should be stripped out?
Commission members made it clear they are concerned about the performance of the PCMH. Hackbarth opened the discussion by stating he believes the PCMH has become “gold-plated” – burdened with so many requirements (“electronic medical records and … 24-hour coverage and a long list of other requirements,” as he put it) that it can’t save money. (p. 267)
Other commissioners concurred. Scott Armstrong (CEO of Group Health Cooperative) and Dr. Rita Redberg observed that giving patients expanded access to doctors via e-mail has greatly expanded “virtual visits” without lowering face-to-face visits. (Armstrong added that “a lot” of what patients talk about in their e-mails “is useless.”) (pp. 275-276) Vice Chair Dr. Michael Chernew said he thought the “administrative requirements” currently imposed on the PCMH were a “hassle” and could outweigh any benefits the PCMH could achieve (p. 288). Willis Gradison said “adding too many requirements … to the structure of primary care” was driving doctors “into the arms of the hospitals.” (pp. 269-270)
Dr. David Nerenz suggested that the PCMH’s problem is more serious than merely being “gold-plated.” He questioned one of the most fundamental premises of the PCMH and all other managed care fads, namely, the claim that “care coordination … pays for itself [through] fewer admissions, fewer readmissions, fewer complications, fewer ED visits, fewer this, fewer that.” [p. 283]
John Christiansen (p. 279) and Peter Butler (p. 306) noted that the large systems that are buying up physician practices may not use PCMH payments for primary care, and Jack Hoadley observed that doctors may not be aware of the small capitation payments most PCMH programs pay to cover “home” services (p. 302).
Drs. Chernew (p. 291) and Rita Redberg (p. 278) noted that a growing body of research questions the conventional wisdom that the PCMH can cut costs by improving quality. Redberg, the editor of JAMA Internal Medicine, noted that she is seeing “a lot of manuscripts” that demonstrate the PCMH is not working as well “as one had hoped.”
Totally missing from this critical review of the PCMH was any discussion of Medpac’s justification for endorsing the PCMH in the first place. By a 16-0 vote, Medpac endorsed the “medical home” in its June 2008 report to Congresshttp://www.medpac.gov/chapters/Jun08_Ch02.pdf . But there was nothing in that report that resembled an evidence-based rationale for the PCMH. The “rationale” the Commission did offer exhibited the features typical of all managed care manifestos: The concept it purported to endorse was extremely vague, it was not supported by evidence, and it was oversold.
The 2008 report listed the usual string of vague attributes “homes” are supposed to have, including “use health IT” and “maintain 24-hour patient communication and rapid access,” the two features Mr. Hackbarth objected to. The report went on specifically to recommend that Medicare impose pay-for-performance schemes on “homes,” and that “homes” be required to use e-mail as a method of maintaining 24-hour access. But the report failed to offer any justification for its recommended list of PCMH features, and cited not a single study in support of the list or any item on the list. The report seemed to say Medpac relied on interviews with “experts” to derive this list, but even that is unclear.
Is it any wonder, then, that Medpac commissioners and staff did not revisit Medpac’s 2008 report for guidance on how to alter the definition of the PCMH in 2014?
Medpac has repeatedly made it clear it endorses the PCMH for the same reasons the American Academy of Family Physicians and other primary care groups did in 2007http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiati… – as a means to bring more resources into primary care and to cut costs. The PCMH is probably not going to cut costs, and consequently it may backfire as a method of strengthening primary care. If we want to strengthen primary care and cut costs at the same time, we will have to enact a single-payer system.
By Tomoko Ono, Michael Schoenstein, James Buchan
OECD Health Working Papers No. 69, April 3, 2014
Doctors are distributed unequally across different regions in virtually all OECD countries, and this causes concern about how to continue to ensure access to health services everywhere. In particular access to services in rural regions is the focus of attention of policymakers, although in some countries, poor urban and sub-urban regions pose a challenge as well. Despite numerous efforts this maldistribution of physician supply persists. This working paper first examines the drivers of the location choice of physicians, and second, it examines policy responses in a number of OECD countries.
The choice of practice location is complex, but across the examined OECD countries, several key factors have emerged in studies of doctors and medical students in recent years. First, the relative unattractiveness as places to live and work is the root of an unequal distribution of physicians across regions and areas. Second, the mode of employment and payment for physicians set the frame for their options for location choices. Third, while incomes for general practitioners in rural regions are higher than those in urban regions in some counties, it may not be sufficient compensation as they work for longer hours and in generally more difficult working conditions. Furthermore, professional prestige plays a role as more prestigious specialties tend to be concentrated in urban areas and by default making rural practice less attractive. Finally rural origins and experience in rural settings are influential factors as doctors who are from rural regions are much more likely to go and practice in rural setting compared to those with an urban upbringing.
While a truly comprehensive regional development policy is helpful to tackle the maldistribution of physicians across regions, policymakers in the health sector have three broad strategies to respond to imbalances in physician distribution.
* The first strategy is to target future physicians to maximize the pool of physicians available for practice in relatively underserved regions. This means increasing the number of qualified physicians who are interested in practice in underserved regions, and/or the number of working hours they are willing to provide. The crucial focal point of action for this strategy is the selection and education of medical students.
* The second strategy is to target current physicians to maximise the share of physicians in the health system who practice in underserved regions. This requires a suitable incentive system, which may include both “carrots and sticks”, i.e. not only financial incentives, but also suitable regulatory measures to influence physicians’ location choices.
* The third strategy is to do with less, i.e. accept that staffing levels will be lower in some regions and focus on service re-design or configuration solutions. This can be done through expansion of involvement in health service delivery by non-physician providers. Service delivery innovations can also make a difference, by the use of technology (e.g. through better use of telemedicine), better management of human resources and their workload, or a combination thereof.
Policymakers in most countries will have to blend a range of elements of these three strategies, and review this mix over time. The best mix of such strategies will depend on various factors: patient needs, demography of the population and the physician workforce, health system characteristics, the budgetary situation, and the overall health reform context. While broad characteristics of interventions can be identified, more robust evaluations are required to improve the evidence basis for these policies and strategies in order to support policymakers to make better informed choices.
All OECD countries experience maldistribution of the physician supply. Of particular concern is the distribution of primary care physicians, especially the lack of their presence in underserved regions. This OECD working paper describes the problem and suggests some approaches to improve distribution.
Currently I am in San Francisco, participating in the National Conference on Primary Health Care Access presented by the Coastal Research Group. The chief of adult medicine of a highly respected California family medicine residency that is noted for training physicians who would more likely practice in community health centers in underserved communities told me that though their program is initially very successful, their graduates experience burn-out, typically after about three years of practice. This is a very serious problem that obviously requires the attention of public policymakers. This OECD report suggests some strategies that could help.
The fact that all OECD nations experience these problems indicates that the health care financing system alone cannot be expected to correct these deficiencies. However, a public financing system, such as single payer, should improve the flexibility to work with the health care delivery system to drive improvement in the distribution of health care professionals. Our current fragmented financing system provides little opportunity to incentivize strategies that might help.
We do need a single payer national health system, but also we need to elect public officials who believe in better health care for all. Although correcting maldistribution will always remain a challenge, there is much that can be done, but we need people in charge who will want do it.
By Brigham Frandsen, James B. Rebitzer
NBER, April 2014
Accountable Care Organizations (ACOs) are new organizations created by the Affordable Care Act to encourage more efficient, integrated care delivery. To promote efficiency, ACOs sign contracts under which they keep a fraction of the savings from keeping costs below target provided they also maintain quality levels. To promote integration and facilitate measurement, ACOs are required to have at least 5,000 enrollees and so must coordinate across many providers. We calibrate a model of optimal ACO incentives using proprietary performance measures from a large insurer. Our key finding is that free-riding is a severe problem and causes optimal incentive payments to exceed cost savings unless ACOs simultaneously achieve extremely large efficiency gains. This implies that successful ACOs will likely rely on motivational strategies that amplify the effects of under-powered incentives. These motivational strategies raise important questions about the limits of ACOs as a policy for promoting more efficient, integrated care.
The growth in the number of accountable care organizations (ACOs) has been phenomenal considering that they are primarily only a wish on the part of the policy community and bureaucrats that such organizations would increase efficiencies to reduce health care spending, especially when earlier results have been very disappointing. This study has added to the doubts about ACOs by showing that incentive payments that they receive will exceed cost savings unless the ACOs “achieve extremely large efficiency gains” – an extremely unlikely outcome.
The policy literature is saturated with these “wish they would work” reports and recommendations to further expand the use of ACOs. The experiment has already failed, and we are meandering back into the disdained managed care organization model disguised as ACOs. The tragedy is that this has distracted our politicians and bureaucrats from moving forward with a model that actually would increase efficiencies, not to mention meeting other goals such as universality and removing financial barriers to care – a single payer national health program.
By Keith Baldrey
Surrey Now, April 8, 2014
Have we finally wrestled that voracious gobbler of tax dollars – the public health-care system – to a standoff, if not to the ground? By that I mean the days of the system automatically devouring increasingly large amounts of money every year to feed itself may be drawing to a close, at least in British Columbia.
Of course, I don’t mean the health-care system will stop being the biggest area of government spending by far (the health-care budget this year is pegged at $16.9 billion, out of a budget of $44.4 billion).
But the rate of growth in spending is slowing down significantly. The annual hike is down to 2.6 per cent this year, compared to just several years ago when it was above five per cent.
Now, there are those who think this is bad news. After all, shouldn’t we be plowing even more money into the system rather than less? If we don’t, won’t health-care standards suffer? The answers are: a) not necessarily and b) no.
The ideological defenders of the public health-care system (who think the answer to everything is to blindly spend gargantuan amounts of more money) think the only measuring stick worth anything is per capita spending. In other words, B.C. should spend more dollars per person than anywhere else, and things will take care of themselves.
But those with experience in the system, who study it and come up with good ideas for change, point to another and far better measurement: health outcomes.
And in that regard, B.C. ranks the highest in the country. While we sit second-to-last in per-capita spending, (only Quebec ranks lower) we beat most other provinces in all kinds of areas: best cancer survival rates, lowest heart attack rate, longest life expectancy, lowest smoking rate, lowest infant mortality rate, etc.
When it comes to wait times for certain surgeries (an admittedly frustrating situation for many people on those wait-lists), they’ve been mostly going down and not up. The median wait time for a hip joint replacement has declined to 13 weeks from 19 weeks over the last 10 years, while a knee joint replacement has gone from 25 weeks to 18 weeks over the same time period.
None of this is to suggest the health-care system does not need constant up-keeping and reform (crowded emergency rooms, for example, seem to be a chronic problem, and we could always use more nurses). But it is encouraging that blind yearly spending hikes are being replaced by newer, innovative ways of spending that are both efficient and lead to healthier outcomes for the users of the system.
Not being able to count on big increases in funding every year has brought some much-needed discipline to the system, and employing some different models has also helped.
One of the most significant changes that is paying off is the government’s relationship with doctors.
In the past, physicians were viewed as costly, self-interested cogs in the system.
Now, however, they are viewed as equal partners who have real responsibilities when it comes to running the health-care system.
For example, several joint committees have been established with the Doctors of B.C. (formerly called the B.C. Medical Association) where doctors and the government shape policies that are aimed at improving patient health, rather than protecting the financial interest of either party.
One committee is for general practitioner services (overseeing improvements to the primary care system), another is for specialist services (aimed at improving access for specialist care) and a third is for shared care (focused on better integration of all levels of care).
As well, something called the Divisions of Family Practice has been created. It links family doctor practices and is designed to improve common healthcare goals in a particular region (improved maternity coverage, for example).
Committees such as these were unheard of a decade ago. They appear to be improving patient care by focusing on smart, evidence-based decisions rather than on simply demanding more money, either for doctors’ pay packets or a health authority’s budget.
The Canada Health Accord between the provinces and the federal government died last week. It means Ottawa will be cutting in half its annual transfer of money to pay for health care.
The fact the B.C. government hardly said a peep about the accord’s demise is evidence of how much the system has changed in the past few years.
Evidence based health care. Why should that be controversial? Yet it is. It provokes accusations of “cook book medicine,” or “bureaucrats interfering with your health care.” Current efforts in British Columbia can provide us with a more rational perspective than is being provided by these negative memes.
Physicians from the B.C. medical association (Doctors of B.C.) and the government are cooperating on efforts to improve patient health in manners other than by simply increasing spending (though that should not be neglected when there is an obvious imperative). Such efforts to spend better rather than simply spending more will be particularly important now that the federal government is being run by individuals who promised to protect Canada’s medicare but instead cut federal spending on the program in half.
Although single payer systems are often criticized for being bogged down by government inflexibility and laggardly progress, the activities in B.C. demonstrate that such processes need not be an inevitability. In fact, B.C. is showing us that their single payer system does have the flexibility to make needed improvements.
In the United States we are currently using models, such as accountable care organizations, supposedly to achieve higher quality at a lower cost. Unfortunately, the model seems to have been misdirected away from efforts to improve health care based on evidence to efforts granting nominal awards based on penny pinching and a few negligible teach-to-the-test measures. Under our fragmented, multipayer system it is difficult achieve widespread adaptation of systemic improvements, simply because it is our unique, dysfunctional financing system that is so inflexible.
This is not to belittle the efforts of AHRQ toward expanding the use of evidence based medicine. Rather it is to make the point that government efforts such as those of AHRQ can be more effective if we get the dysfunctional financing system out of the way, especially the intrusive private insurers, and allow AHRQ and other public entities to cooperate more effectively with the people actually delivering health care.
By Andrew Ryan, Matthew Sutton and Tim Doran
HSR, April 2014
To test whether receiving a financial bonus for quality in the Premier Hospital Quality Incentive Demonstration (HQID) stimulated subsequent quality improvement.
Under the HQID, hospitals received a 1 percent bonus on Medicare payments for scoring between the 80th and 90th percentiles on a composite quality measure, and a 2 percent bonus for scoring at the 90th percentile or above.
We found little evidence that hospitals’ receipt of quality bonuses was associated with subsequent improvement in performance. This raises questions about whether winning in pay-for-performance programs, such as Hospital Value-Based Purchasing, will lead to subsequent quality improvement.
Quality derives from dedicated professionals, working within a well-designed health care infrastructure, striving to obtain the best health care for their patients.
Politicians and the policy community seem to miss this point as they continue to look for administrative gimmicks that are essentially managed care innovations. What we don’t need in the United States is more administrative excess. Pay-for-performance (P4P) continues to fail as an incentive for true quality improvement, even if some studies have shown almost worthless teach-to-the-test increases in scores.
If we really want quality, we need to work on our health care infrastructure, beginning with implementing a financing system that drives quality – a single payer national health program.
By Paul Krugman
The New York Review of Books, May 8, 2014
By Thomas Piketty, translated from the French by Arthur Goldhammer
Belknap Press/Harvard University Press, 685 pp., $39.95
Thomas Piketty, professor at the Paris School of Economics, isn’t a household name, although that may change with the English-language publication of his magnificent, sweeping meditation on inequality, Capital in the Twenty-First Century. Yet his influence runs deep. It has become a commonplace to say that we are living in a second Gilded Age — or, as Piketty likes to put it, a second Belle Époque — defined by the incredible rise of the “one percent.” But it has only become a commonplace thanks to Piketty’s work.
The big idea of Capital in the Twenty-First Century is that we haven’t just gone back to nineteenth-century levels of income inequality, we’re also on a path back to “patrimonial capitalism,” in which the commanding heights of the economy are controlled not by talented individuals but by family dynasties.
This is a book that will change both the way we think about society and the way we do economics.
Capital in the Twenty-First Century is, as I hope I’ve made clear, an awesome work. At a time when the concentration of wealth and income in the hands of a few has resurfaced as a central political issue, Piketty doesn’t just offer invaluable documentation of what is happening, with unmatched historical depth. He also offers what amounts to a unified field theory of inequality, one that integrates economic growth, the distribution of income between capital and labor, and the distribution of wealth and income among individuals into a single frame.
The current generation of the very rich in America may consist largely of executives rather than rentiers, people who live off accumulated capital, but these executives have heirs. And America two decades from now could be a rentier-dominated society even more unequal than Belle Époque Europe.
But this doesn’t have to happen.
At times, Piketty almost seems to offer a deterministic view of history, in which everything flows from the rates of population growth and technological progress. In reality, however, Capital in the Twenty-First Century makes it clear that public policy can make an enormous difference, that even if the underlying economic conditions point toward extreme inequality, what Piketty calls “a drift toward oligarchy” can be halted and even reversed if the body politic so chooses.
The key point is that when we make the crucial comparison between the rate of return on wealth and the rate of economic growth, what matters is the after-tax return on wealth. So progressive taxation — in particular taxation of wealth and inheritance — can be a powerful force limiting inequality. Indeed, Piketty concludes his masterwork with a plea for just such a form of taxation. Unfortunately, the history covered in his own book does not encourage optimism.
Piketty ends Capital in the Twenty-First Century with a call to arms — a call, in particular, for wealth taxes, global if possible, to restrain the growing power of inherited wealth. It’s easy to be cynical about the prospects for anything of the kind. But surely Piketty’s masterly diagnosis of where we are and where we’re heading makes such a thing considerably more likely. So Capital in the Twenty-First Century is an extremely important book on all fronts. Piketty has transformed our economic discourse; we’ll never talk about wealth and inequality the same way we used to.
Hopefully the excerpts above from Paul Krugman’s review of Thomas Piketty’s “Capital in the Twenty-First Century” will entice you to read Krugman’s full review, and then that will entice you to read Piketty’s full book. If you do so, you’ll understand why Krugman says, “we’ll never talk about wealth and inequality the same way we used to.”
Although a book on capital would seem to be off the topic of health care, Piketty provides us with the background to understand why we can’t seem to get health care financing right here in the United States, though he doesn’t discuss it specifically.
We do use progressive tax policies to partially fund health care through general revenues, but we also burden wage earners with the cost of health plans partially financed through regressive tax expenditures – the tax deductibility of employer-sponsored plans paid by employees through forgone wage increases.
Whereas median household income in the United States is now about $50,000, the cost of health care for the typical family of four is now about $22,000 (Milliman Medical Index). These numbers no longer compute, but they tend to be lost in the fragmented, dysfunctional way in which we finance health care. They cry out for reform.
There are two general approaches – on spending and on revenues – that seem to be imperative. One would be to reduce the wasteful spending in health care that occurs from our profound administrative excesses, our high prices, and the maldistribution of our resources due to a lack of adequate public oversight. A single payer system would redirect our resources to much better use.
The other approach that we need – as the disconnect between income and health costs demonstrates – would be to fund the single payer system through much better defined progressive taxes. Piketty’s treatise shows us that we really don’t have any other alternative. And since we already spend such a large portion of our GDP on health care, a progressively financed single payer system would provide a significant step in the visionary direction that Piketty has laid out for us.
By Karin V. Rhodes, MD, MS; Genevieve M. Kenney, PhD; Ari B. Friedman, MS; Brendan Saloner, PhD; Charlotte C. Lawson, BA; David Chearo, MA; Douglas Wissoker, PhD; Daniel Polsky, PhD
JAMA Internal Medicine, April 7, 2014
The goal of the current study was to simulate the experience of nonelderly adults with 1 of 3 insurance types—private, Medicaid, and uninsured—seeking new patient appointments in 10 diverse states to obtain precise estimates of primary care access before the ACA coverage expansions.
Between November 13, 2012, and April 4, 2013, we made 12,907 calls to 7788 primary care practices requesting new patient appointments. Across the 10 states, 84.7% of privately insured and 57.9% of Medicaid callers received an appointment. Appointment rates were 78.8% for uninsured patients with full cash payment but only 15.4% if payment required at the time of the visit was restricted to $75 or less.
This study reveals the success rates in obtaining a primary care appointment as a new patient by non-elderly adults, prior to full implementation of the Affordable Care Act. So what was it like then, what will the Affordable Care Act do for that, and what would single payer have done to change the results?
Being privately insured provided the greatest probability of success in obtaining an appointment – 85% were able to do so. Close to that – at 79% – were new patients who would pay cash in full at the time of the visit. Medicaid patients had more difficulty – with only 58% being able to make an appointment. Worst of all was for those who would pay cash, but no more than $75 at the time of the visit – only 15% were successful.
Of course, this is what we’ve known all along. Privately insured patients have good access, Medicaid patients have poorer access by virtue of being covered by an underfunded welfare program, and uninsured patients with limited resources have the worst access of all. Those willing to pay cash in full may have been covered by a high-deductible plan but, in any event, were likely to to have the means to pay upfront charges. So money or good insurance will open the doors, whereas Medicaid is dependent on the willingness of the primary care provider to participate in the Medicaid program, and being poor and uninsured… well, good luck.
What will happen now that ACA is well on its way to full implementation? The answer is complex, which is no surprise because the ACA model is itself complex. Let’s look at each category of coverage.
For the very wealthy who are quite willing to pay full fees in cash, and the scheduling staff of the primary care practice understands that, access should approach 100%. If any queues exist, those individuals likely can buy their way to the front of the queue.
For privately insured individuals, whether obtaining coverage through employment or through individually purchased plans within or outside of the exchanges, access may be less than it is now since insurers with the new narrower networks exclude many primary care professionals from their panels. Most individuals will not want to select an out-of-network primary care professional, especially since out-of-pocket costs could be staggering since the cap applies only to in-network care (except for certain emergencies).
Even those employer-sponsored plans that ACA was designed to protect are now moving in the direction of higher deductibles, narrower networks, and even private exchanges with a shift to defined-contribution vouchers. Although the percentage of practices accepting specific insurance plans will decline because of the doctor being excluded from the networks, patients will probably still choose private plans as being their best option. It’s just that they will have to shop more before they find practices that accept their specific insurance.
Finding primary care practices that accept Medicaid may be more difficult. Although there is a temporary increase in primary care evaluation and management payments, that will end very soon. It is likely that there will not be much of an increase in the number of physicians who will agree to accept the low Medicaid payment rates. If those who do accept Medicaid find that the increased volume is crowding out their privately insured patients, then they may feel that they have to cut back or eliminate accepting new Medicaid patients as well.
With an increase in Medicaid managed care organizations, Medicaid patients may have this option, but then that limits their access since they must go to the managed care providers. Also the low payment rates for Medicaid managed care organizations may result in relatively spartan care merely because of the insufficiency of funds. Another possibility is that federally-qualified health centers may be able to increase their capacity because of new funds authorized by ACA. Hopefully these two expansions will provide enough capacity to ensure access of Medicaid patients to at least some form of primary care.
Access for the low-income uninsured – and there will be tens of millions of them – will certainly continue to be impaired. If Congress further expands the funding of federally-qualified health centers, then the uninsured will have that option. But specialized care will likely be out of reach for most.
So, in general, access to primary care is unlikely to change to any major degree as the result of the provisions of ACA. Patients will have less choice of providers, more exposure to out-of-pocket costs, but an increase in funding should improve access to other options such as Medicaid managed care organizations or federally-qualified health centers – especially important for low-income individuals.
What if we had a single payer system instead? Primary care practices would never have to ask a new patient what insurance they had, or whether they intended to pay cash. Patients would never have to check network lists to see whom they could call. (There would still be some “networks” such as Kaiser Permanente, but they would be integrated health systems that patients would choose because of their own preferences.)
With single payer, never again would a new patient have to hear this response from a receptionist: “New patient? What kind of insurance do you have? Oh, I’m sorry. The doctor isn’t able to accept any new patients now.”
(Unless you are a masochist, skip down to the comment at the end. The following excerpts from the CMS documents are merely to provide verification for the statements in the comment.)CMS Ensures Higher Value and Quality for Medicare Health and Drug Plans
CMS, April 7, 2014
Today, the Centers for Medicare & Medicaid Services (CMS) issued the 2015 rate announcement and final call letter for Medicare Advantage and prescription drug benefit (Part D) programs.
Payments to Medicare Advantage Plans:
* CMS estimates that the overall net change to plan payments between 2014 and 2015 to be +0.4 percent, compared to the estimated overall net change to plan payments of -1.9 percent for the proposals in the Advance Notice Individual plan payments will vary by plan based on, but not limited to, its location and star rating.
* Before the Affordable Care Act, Medicare Advantage plans were paid more than 10 percent compared to traditional Medicare, costing the program more than $1,000 per person each year, while quality and health outcomes were similar to those enrolled in traditional Medicare. The changes underway reduce excessive payments to Medicare Advantage plans, while incentivizing quality improvements by basing part of Medicare Advantage payment on plan quality performance.
* To provide for continued stability in the Medicare Advantage program, CMS will implement a new phase-in schedule for the Part C risk adjustment model introduced in 2014. In addition, to improve payment accuracy, CMS has refined its risk adjustment methodology to account for the impact of the influx of baby boomers. In addition, for 2015, CMS will not finalize the proposal to exclude diagnoses from enrollee risk assessments.
****Announcement of Calendar Year (CY) 2015 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter
CMS, April 7, 2014
Key Changes from the Advance Notice:
CMS-HCC Risk Adjustment Models for CY2015
Medicare Advantage Enrollee Risk Assessments
RxHCC Risk Adjustment Model
International Classification of Diseases-10 (ICD-10) Code Sets and Diagnosis Data Sources for 2015 Risk Scores:
Section A. Final Estimate of the National Per Capita Growth Percentage and the Fee-for- Service (FFS) Growth Percentage for Calendar Year 2015
Comment: Several commenters had concerns about the magnitude of changes proposed in the Advance Notice and the potential impact to Medicare beneficiaries and plans. Commenters raised concerns that the payment reductions described in the Advance Notice would lead to significantly higher MA premiums, significantly reduced benefits, or both. Some commenters argued that these cuts would lead to MA plans exiting the market. Some providers noted that the reductions to MA contained in the Advance Notice would seriously threaten their ability to provide high quality care to beneficiaries. We also received comments that the cuts would lead to market contraction, less competition, and ultimately less access for beneficiaries. Commenters requested that we keep Medicare Advantage revenue flat for 2015.
Response: We are committed to a strong, stable Medicare Advantage program and to continued access to high quality plan choices for Medicare beneficiaries. Over the past several years, even as the Medicare Advantage program transitioned to payments that are more aligned with FFS Medicare costs, enrollment in Medicare Advantage has increased to an all-time high of approximately 15 million beneficiaries. Today, nearly 30 percent of Medicare beneficiaries are enrolled in a Medicare Advantage plan and benefits remain stable. We believe that the proposals outlined in the Advance Notice will continue the transition to payments that are more comparable to FFS costs, while at the same time continuing the trend toward greater enrollment in high quality plans.
Section G. CMS-HCC (Hierarchical Condition Category) Risk Adjustment Model for CY 2015
Comment: We received a few comments opposing our proposal to use a blend of the 2013 CMS-HCC model and 2014 CMS-HCC model in 2015, and supporting instead calculating risk scores using exclusively the 2013 CMS-HCC model. Many commenters were in support of continuing to use a blend of risk scores from two different models. Two commenters were in favor of ending the phase-in of the clinically revised model introduced in 2014 and calculating risk scores in 2015 using only this model.
Response: As we remain committed to the clinically revised model introduced for the 2014 payment year, we will not use risk scores exclusively from the 2013 CMS-HCC model as recommended by some commenters. Because we still believe that additional time to transition to the 2014 model is needed, we also will not use risk scores from the 2014 model exclusively as recommended by two commenters, and will continue for 2015 payment year to blend the risk scores calculated using the 2013 CMS-HCC and 2014 CMS-HCC models.
In light of the impact of the final payment updates and changes for 2015, however, we are concerned that the use of the 2014 blend percentages of 75% and 25% that we proposed to continue in the Advance Notice would not have the same effects on payment stability that they had last year, and that we assumed they would have when proposing them this year. As in 2014, we will continue to blend the risk scores from the old and new models, in order to both support our intention to move to the updated model while also providing time for plans to transition to its use in payment. Thus, to further our goal of promoting stability and given concerns about the impact of payment changes for 2015, we will blend the two scores using a 67 percent and 33 percent blend, respectively. Specifically, we will blend the risk scores calculated using the 2014 CMS-HCC model with risk scores using the 2013 CMS-HCC model, each appropriately normalized, weighting the normalized risk scores from the 2013 model by 67 percent and the normalized risk scores from the 2014 model by 33 percent. These risk scores from the 2013 and 2014 CMS-HCC models will include the risk scores calculated from the community, institutional, new enrollee, and C-SNP new enrollee segments of the model and will be used in Part C payment for aged/disabled beneficiaries enrolled in MA plans. See Section II.G of the 2014 Advance Notice and Section III.D of the 2014 Rate Announcement for more details on the clinically revised CMS-HCC model.
Section H. Medicare Advantage Enrollee Risk Assessments
Comment: Many commenters opposed the proposal to exclude diagnoses that resulted from home visits, including enrollee risk assessments, unless there was a subsequent clinical encounter.
Response: CMS continues to support the use of enrollee risk assessments for wellness, care coordination, and disease prevention; however, we remain concerned that many home visits are being used primarily for the gathering of diagnoses for payment rather than to provide treatment and/or follow-up care to beneficiaries. We recently instituted a new requirement for MA organizations to identify, in the diagnoses they submit to CMS, which diagnoses are from home visits. These new data will enable CMS, for the first time, to evaluate how many diagnoses are identified in home visits and to assess what effect the home assessments have on the care provided to beneficiaries. In order to allow our policy to be informed by this analysis, we have decided not to implement the proposal to exclude diagnoses from home visits for 2015 payments. We will study the data submitted by MA organizations to determine appropriate policy options for consideration for 2016 and future years.
Section J. Normalization Factors
Comment: The majority of commenters supported CMS’ proposal to calculate the normalization factors for the CMS-HCC and RxHCC risk scores using a methodology to better capture the increased proportion of younger beneficiaries known as the “baby boomers.” Several commenters recommended that CMS make retroactive adjustments to the normalization factors.
Response: We appreciate the support for modifying the normalization factor methodology to account for the influx of baby boomers to the Medicare population. CMS uses historical data to develop normalization factors prior to a payment year in order to promote stability for bidding purposes. Given this policy, CMS will not retroactively change the normalization factors for prior years. However, we did consider whether using more historical data could better inform the calculation of the 2015 normalization factors (in the Advance Notice we proposed using 2012 and 2013 risk scores to estimate annual trends for the CMS-HCC models). By using a quadratic functional form fit to risk scores from 2010 through 2013, the normalization factors will better reflect more recent changes in the population trends. Thus, we are finalizing the 2015 normalization factors for the CMS-HCC and RxHCC models as shown in Table III-2:
Excerpts from Table III-2 2015 Normalization Factors:
0.992 CMS-HCC model implemented in 2013
0.978 Clinically revised CMS-HCC model implemented in 2014
Comment: A number of commenters asked for more transparency around the calculation of the normalization factors.
Response: In Table III-3. below, we show the risk scores used to calculate the normalization factors for 2015.
Excerpts from Table III-3. 2010-2013 Risk Scores Used to Calculate 2015 Normalization Factors
CMS-HCC model implemented in 2013
Clinically revised CMS-HCC model implemented in 2014
To access this 154 page announcement, at the following link select “Announcements and Documents” from the left column, and then select “”2015 Announcement” with a release date of “2014-04-07”: http://www.cms.hhs.gov/MedicareAdvtgSpecRateStats/
****Washington insiders crossing the line in defense of Medicare Advantage
Quote of the Day, April 3, 2014
The Affordable Care Act included provisions to reduce these overpayments to levels comparable to the costs of patients in the traditional Medicare program. AHIP has already used its influence to convince the administration to use chicanery to reduce the cutbacks in the first two years of the reductions (by issuing phony quality awards and by using accounting gimmickry with the scheduled but deferred SGR adjustments). Since the administration seems to be resisting further chicanery (we’ll soon find out) AHIP has intensified its public campaign using some of Washington’s “finest.”
In an effort to privatize Medicare, conservatives in Congress enacted legislation to provide private Medicare Advantage plans with a 14 percent overpayment in order to unfairly compete with the traditional Medicare program. The Affordable Care Act included measures to gradually eliminate this overpayment. CMS appears to be thwarting the intent of Congress to correct this injustice.
Because of pressure from the insurance industry, the Obama administration used chicanery in the first two years of the ACA implementation to maintain higher Medicare Advantage rates. This year the reduction was to have been 1.9 percent. So the insurance industry initiated an intensive campaign to reverse these reductions. Once again, CMS has used more chicanery to convert their reduction into a 0.4 percent gain – reassuring private insurers that they can continue to expand their private takeover of Medicare.
There are numerous gimmicks that were used, and some of them are quite obscure. For instance, perhaps the most important revision was in the “normalization factors.” Because of the influx of baby boomers into the Medicare program, it was decided to use “a quadratic functional form fit to risk scores from 2010 through 2013” in the CMS Hierarchical Condition Category. To provide “transparency around the calculation of the normalization factors,” they showed “the risk scores used to calculate the normalization factors for 2015.” Glad that’s clear.
Seriously, CMS has used innovative accounting to increase payments to Medicare Advantage plans based on the fact that there is an influx of baby boomers – a subset of Medicare beneficiaries that is younger, healthier, and less expensive than the older beneficiaries already enrolled. Taxpayers will pay more for lower cost beneficiaries. I remember the quadratic equation, but I don’t remember it ever being used to cheat taxpayers and reward the private insurer rentiers.
Rentiers? Those are individuals whose income is derived from capital, and now our nation’s capital is being concentrated in the top centile. If you missed yesterday’s Quote of the Day on Thomas Piketty’s “CAPITAL,” you should not bother reading the CMS song and dance above, and instead read yesterday’s message.
Congress and the Obama administration are serving the interests of the rentiers, and this Medicare Advantage payment scam is only one example. It is time for the people to take control. As Thomas Piketty wrote, “if we are to regain control of capitalism, we must bet everything on democracy.”
qotd: Thomas Piketty – “CAPITAL in the Twenty-First Century”:http://www.pnhp.org/news/2014/april/thomas-piketty-capital-in-the-twenty…
By Thomas Piketty
Harvard University Press
The overall conclusion of this study is that a market economy based on private property, if left to itself, contains powerful forces of convergence, associated in particular with the diffusion of knowledge and skills; but it also contains powerful forces of divergence, which are potentially threatening to democratic societies and to the values of social justice on which they are based.
The principle destabilizing force has to do with the fact that the private rate of return on capital, r, can be significantly higher for long periods of time than the rate of growth of income and output, g.
The inequality r>g implies that wealth accumulated in the past grows more rapidly than output and wages. This inequality expresses a fundamental legal contradiction. The entrepreneur inevitably tends to become a rentier, more and more dominant over those who own nothing but their labor. Once constituted, capital reproduces itself faster than output increases. The past devours the future.
The consequences for the long-term dynamics of the wealth distribution are potentially terrifying, especially when one adds that the return on capital varies directly with the size of the initial stake and that the divergence in the wealth distribution is occurring on a global scale.
The problem is enormous, and there is no simple solution.
Many people worry that moving toward greater cooperation and political integration within, say, the European Union only undermines existing achievements (starting with the social states that the various countries of Europe constructed in response to the shocks of the twentieth century) without constructing anything new other than a vast market predicated on ever purer and more perfect competition. Yet pure and perfect competition cannot alter the inequality r>g, which is not the consequence of any market “imperfection.” On the contrary. Although the risk is real, I do not see any genuine alternative: if we are to regain control of capitalism, we must bet everything on democracy.
Although the English translation of Thomas Piketty’s “CAPITAL in the Twenty-First Century” was published only this month, it has already become a classic in the economics literature. This book is not about health care, but it provides us with an excellent background for understanding why we need to reform our current health care financing system. It is a must read, not just for those advocating for health care reform, but for everyone.
Our health care system is designed to support rentiers. Current trends in income and in wealth accumulation indicate that a disproportionate share of global income will continue to shift more and more to the control of the rentiers. We are already seeing a relative decline in financing of health care for wage earners, manifested by higher cost sharing and by more limited access through narrower, lower-cost provider networks.
Piketty shows us how the concentration of capital at the top drives an ever greater percentage of income upwards, with the rentiers having to do nothing further to accomplish that feat. He explains how the solution is progressive income taxes and progressive wealth taxes.
Expanding progressive financing through single payer would provide a step forward in implementing solutions to the iniquities of concentrated wealth. And it would be a significant move since health care constitutes such a large part of our GDP.
Without intervention, there is the risk of major social disruption. If we wish to avoid this, people are going to have to rediscover democracy. As Thomas Piketty says, “if we are to regain control of capitalism, we must bet everything on democracy.”
Panel: Atul A. Gawande, M.D., M.P.H., Carrie H. Colla, Ph.D., Scott D. Halpern, M.D., Ph.D., M.Bioethics, and Bruce E. Landon, M.D., M.B.A., M.Sc.
The New England Journal of Medicine, April 3, 2014
(Excerpts here are not in continuity.)
Atul Gawande: When a service is widely recognized as providing little or no benefit, or maybe even harm, what should be done to reduce its use?
I want to start with a seemingly simple question. How do you define low-value care?
Bruce Landon: It turns out that there are very, very few services that are low-value in all clinical situations. So I actually think it’s really important to use a clinical lens, and particularly for, as I’m taking care of patients, it’s a lens that really focuses on that patient in front of me.
Scott Halpern: Well, I think it’s incredibly difficult to draw lines, particularly because all our definitions are predicated at the population level. And population-level estimates don’t apply very naturally to individual patients.
So when we describe something as low-value, I think what we’re typically trying to do is to distinguish it from something that is no-value. But it turns out that no-value interventions, first of all, are probably very few and far between. There are very few things we do in medicine that truly could not help any patient to which we might consider applying it.
Landon: I think it’s going to be hard to address the problem of low-value care by having payers and policymakers make rules, because there’s this clinical heterogeneity story.
Halpern: The right rates at which we utilize these quote-unquote low-value services is not zero. We don’t want to practice so frugally that we’re missing opportunities to provide benefits to patients by not intervening. So I think at some level, physicians should be comfortable that they can make clearly well-thought-out choices that, although there are recommendations not to do things for the overwhelming majority of patients who fit a particular description, that there may be exceptions where the service is in fact a reasonable choice.
Carrie Colla: I think that there’s a danger that blunt payment instruments will reduce the high-value care as well, and so I think to some extent that’s why thinking about it at a broader level while also monitoring outcomes, but thinking about it at a broader level in terms of payments makes more sense.
Gawande: What would you say that the policies of the government ought to be, or of insurers ought to be, in order to make sure decision making more effective for both patients and physicians under these circumstances?
Halpern: If we had one health insurance coverage system, all the prices would be a lot easier to keep track of, for physicians and patients alike. And it would be much easier to have a set menu at the bedside as these conversations are unfolding, of all the types of information that we would want. I recognize that may be a long way away. But it is one of the sort of unintended consequences of our variegated reimbursement system as it exists today.
Video (30 minute) and link to transcript:http://www.nejm.org/doi/full/10.1056/NEJMp1401245?query=TOC
Diagnostic and therapeutic interventions that are of low value remain a dilemma. In this age with an emphasis on containing costs, should interventions that have a high cost in relation to an anticipated minimal or negligible benefit be avoided simply to help “bend the cost curve”? Or should such interventions be offered since even the smallest potential benefit should not be withheld from the patient if the patient desires such?
The easiest decision to be made would be about interventions that clearly provide no benefit under any circumstances, and may even potentially inflict harm. This is not low-value care, but rather it is no-value care. Obviously such interventions should be abandoned. For the few health care professionals using them who fail to respond to educational processes, discipline should be considered.
What about interventions that have a significant risk of major harm but could provide a small benefit that is not commensurate with the potential harm? Clinical judgement begins to enter here, but it would be a rare circumstance where other factors may warrant proceeding with the intervention.
What about the intervention that is very expensive but potentially provides only minimal benefit? Although some might use measures such as anticipated increase in quality-adjusted life years (QALY), there are levels of spending that common sense tells you are far beyond the value of the potential benefit. Rejecting such interventions risks being labeled as rationing, but such a charge does not mean that common sense should be abandoned.
A variation of this category would be lucrative procedures in widespread use for which only a paucity of conflicting data provides a rationale for these practices – high cost but low benefit. Sometimes these correlate with excess capacity in the system, a problem that separate budgeting of capital improvements could improve. Also, administered pricing could lower payments to more closely match the extent of the benefit.
What about the expensive diagnostic intervention that has a very low probability of of turning up a disorder for which therapeutic interventions could be of great benefit, perhaps even life saving? This is where clinical judgement and being sure that the patient is well informed play a crucial role. This is also where those citing the Dartmouth studies hope to reduce health care spending. But if a low-yield test has a real chance of leading to an intervention of potentially great benefit, then the payer should not intervene.
A frequent criticism is that such low-yield tests are done too often to reduce the risk of a malpractice lawsuit, and that we could reduce the costs of malpractice if we did away with these “unnecessary” tests. Since such tests are low yield, frequently nothing significant is found and therefore no lawsuit was prevented. But the judgement should not be based on the cost per lawsuit prevented, but rather on the clinical benefit to the patient. This is why attacking low-yield tests is not a productive way of reducing malpractice costs.
What about the patient who demands an intervention when it is clear that there is no value in what the patient wants? It is the health care professional’s responsibility to inform the patient why such an intervention should not be entertained. Most patients will appreciate informed advice. For the rare ones that do not, physicians should never conspire with a patient to do wrong, even if it results in the patient seeking care elsewhere.
In all of these situations, the interests of the patient must come first. Clinical judgement is required for most of them.
So how do we address the costs? The current leading approaches are to erect financial barriers to care and to impair access by using narrow provider networks. These interventions are inappropriate because they save costs by preventing the patients from receiving appropriate care that they should have.
There is a far better method of reducing inappropriate spending, and that would be to enact a single payer system – an improved Medicare for all. Such a model dramatically reduces administrative waste and improves pricing of health care services. Under a single payer system it is much easier to match payment with value.
By Mark Duggan, Amanda Starc, and Boris Vabson
National Bureau of Economic Research, March 2014
Our results strongly suggest that increased subsidies for private insurance in the Medicare market result in increased insurer advertising, but little additional monetary or medical benefit for consumers.
The measures of plan financial characteristics and quality that we use suggest that only about one-sixth of the policy-induced increase in plan reimbursement is captured by consumers.
While reimbursement increases have an ambiguous welfare impact on consumers, they unambiguously increase costs, through increased numbers of MA enrollees and through increased government spending per MA enrollee. A back-of-the-envelope estimate suggests that this additional spending amounted to approximately $6.4 billion during the final year of our sample period
****40 Senators Sign Bipartisan Letter Urging CMS to Maintain Current Medicare Advantage Payment Levels in 2015
AHIP, February 18, 2014
****Stakeholder Groups Send Bipartisan Letter Urging CMS to Protect Seniors in Medicare Advantage
AHIP, March 7, 2014
****140 Physician Organizations Sign CAPG Letter Urging CMS to Protect Seniors in Medicare Advantage
AHIP, March 10, 2014
****204 Members of Congress Sign New Bipartisan Letter Urging CMS to Protect Seniors in Medicare Advantage
AHIP, March 13, 2014
****What They Are Saying: Bipartisan Group of 262 Members of Congress Urges CMS to Protect Seniors in Medicare Advantage
AHIP, March 28, 2014
****Dr. Kavita Patel and John Rother: Proposed Medicare Advantage Cuts “Unjustifiable”
AHIP, March 19, 2014
****Medicare cuts put coordinated care at risk
By John Rother, JD and Kavita K. Patel, MD MS
The Hill, March 13, 2014
In the last few years, growth in healthcare spending has begun to moderate, fueled in part by Medicare’s shift toward new forms of payment based on outcomes and quality. But short-sighted regulations proposed last week would impose dramatic cuts to Medicare Advantage (MA) that may stifle this exciting transformation.
Many of the new cost-containment strategies now underway in original Medicare were pioneered in Medicare Advantage. The models for the Affordable Care Act (ACA)’s Accountable Care Organizations were integrated delivery systems like Intermountain, Kaiser Permanente and Geisinger, which all operated MA plans.
The Center for Medicare and Medicaid Innovation is currently testing a nurse-led care coordination program in nursing homes that is strikingly similar to United Healthcare’s Evercare program. And under the so-called Dual-Eligibles Demonstrations, states, Medicaid and Medicare are working together to implement the successful chronic care strategies pioneered by specialized MA Special Needs Plans like SCAN Health Plan, Caremore and XL Health.
Last year the very plans that developed these innovations weathered a 6.7 percent cut in payment. The effect of the cut was predictable: a majority of counties across the country saw fewer plan options, premiums climbed 6 percent and out of pocket maximums jumped an average of $560. But now, after federal regulators issued a new proposal February 21, MA appears to be headed for an entirely new round of cuts.
The new cuts would slice another 5.9 percent from Medicare Advantage this year. That amounts to nearly 15 percent in cuts over just two years. This trend is unsustainable without imposing real costs to Medicare and its beneficiaries.
Regulators have offered several rationales for these cutbacks, which can sound plausible at first when considered one by one. After all, Congress did redirect some MA funding to offset costs associated with the ACA, and slower cost growth elsewhere in Medicare arguably would mean some adjustment for MA. However, after examining the overall, cumulative impact of this latest proposal, it’s clear that regulators are missing the forest for the trees.
Continued cuts of this magnitude put at risk the next generation of new cost-saving and quality-enhancing reforms. Even as today’s models of accountable care and primary care innovation are taking hold elsewhere in health care, MA plans would be falling behind due to the forced limit on their investment in cost-curbing strategies. That is bad news for the taxpayers who must help finance Medicare today and in the decades to come.
But the consequences for beneficiaries are even more concerning. As the proposed cuts force plans to pull back from markets they currently serve, some seniors and disabled Americans will have fewer integrated care options from which to choose, or even none at all. For any Medicare enrollee, this is a scenario to avoid. But when you consider how 41% of Medicare beneficiaries make less than $20,000 a year, the proposal becomes unjustifiable.
The Center for Medicare and Medicaid Services (CMS) has the authority to prevent this scenario. They must exercise it.
One element of a smarter approach could be to extend a recently-concluded quality demonstration project. Current law requires CMS to pay bonuses to MA plans that earn 4 or 5 stars in CMS’ 5 star plan evaluation system. But when a now-concluded demonstration program allowed CMS to offer bonuses to 3 and 3.5 star plans, there was a marked improvement in plan quality across MA as plans invested in better care management and partnered with providers to offer the high-value care that patients need. Resurrecting the demonstration would be win/win by mitigating damaging rate cuts for plans while promoting even better quality across the MA program. And rather than denying many beneficiaries the option of pursuing integrated care, continuing the quality demonstration would actually improve the quality of the options availability to them.
Whatever the exact regulatory levers used to reverse the proposed cuts, CMS must change its course. Blunt cuts will only stifle the very innovation which policymakers, providers and patients are so desperate to pursue in a new era of delivery system reform.
The extraordinary power of AHIP – the health insurance lobby organization – is currently being demonstrated by its astonishing ability to massively recruit Washington insiders and politicians in its effort to salvage the overpayments being made to the private Medicare Advantage plans.
If you review the letters, op-eds, and press releases of the various individuals and organizations that have recently spoken out in support of Medicare Advantage, you will see that they all use the rhetoric of AHIP. The AHIP release of March 28 (link above) shows the extent of involvement of members of Congress, including links to their letters and op-eds, obviously orchestrated by AHIP.
The op-ed reproduced in full above demonstrates not only the use of obvious AHIP rhetoric, but it shows how pervasive the AHIP efforts have been in that they were able to recruit two respected members of the policy community to sign on to this op-ed – John Rother and Kavita Patel. This Washington sellout to AHIP is not just sad, it’s tragic.
It is not as if there were some saving grace in the private Medicare Advantage plans. The new study from NBER (above) is only the latest amongst the innumerable reports showing that most of the extra funds paid to the plans are going to the insurers rather than the beneficiaries. This particular study shows that the insurers are using our tax funds to buy advertising to sell more plans to jack up their revenues. The advertising campaign has been successful in that one-third of Medicare beneficiaries have now enrolled in the private plans.
The Affordable Care Act included provisions to reduce these overpayments to levels comparable to the costs of patients in the traditional Medicare program. AHIP has already used its influence to convince the administration to use chicanery to reduce the cutbacks in the first two years of the reductions (by issuing phony quality awards and by using accounting gimmickry with the scheduled but deferred SGR adjustments). Since the administration seems to be resisting further chicanery (we’ll soon find out) AHIP has intensified its public campaign using some of Washington’s “finest.”
The main claim that AHIP has induced these Washingtonians to make is that seniors on the Medicare Advantage program will have to pay more since the insurers will have to increase premiums and cost sharing to make up for the reduced government payments. What they don’t point out is that reductions in premiums and cost sharing amount to only about one-sixth of the overpayments that the insurers receive.
Think about those numbers. If the Medicare Advantage program were shut down and everyone in Medicare were granted the same reductions in premiums and cost sharing as those in the Medicare Advantage plans, then the entire cost would be only half of total amount of the overpayments that the Medicare Advantage plans are already receiving (tripling the number of people receiving one-sixth of the overpayments).
If members of Congress cared more about the people instead of the insurers, they would respond to the pleas of “don’t cut my Medicare” by telling their constituents that not only will they protect the savings the Medicare Advantage patients are receiving, but they also will give the same savings to everyone else on Medicare, and they will pay for it by getting rid of the Medicare Advantage plans and have a lot of money left over.
What we don’t want to pay for is more expensive advertising to draw people into a program that wastes our taxpayer dollars while rewarding AHIP’s sponsors. Even if John Rother and Kavita Patel become remorseful and do the right thing, unfortunately the members of Congress know that AHIP lobbyists are the ones who will show them the money.
If we expect to use an improved version of Medicare as a model for single payer reform, we are going to have to get rid of the private insurers – the Medicare Advantage plans.
By Miranda Dietz, Dave Graham-Squire, and Ken Jacobs
UC Berkeley Labor Center, April 2014
Projections for enrollment in the new insurance options created under the Affordable Care Act (ACA) are often point-in-time estimates. But just as people frequently move in and out of being uninsured, insurance coverage through Covered California (California’s health insurance marketplace) or through Medi-Cal is dynamic and can change for an individual over the course of a year.
Following each cohort across 12 months and observing changes in income, take up of employer sponsored insurance (ESI), and loss of insurance recorded in the SIPP, the analysis predicts the share of those originally enrolled who will remain in the same type of coverage at the end of the 12 months.
For individuals enrolled in Medi-Cal:
74.5% Stay in Medi-Cal
16.5% Income increases, eligible for Covered California
9.1% Leave for job-based coverage
0.0% Become uninsured (zero “unlikely to hold in reality”)
For individuals enrolled in Covered California (range between stronger and weaker retention scenarios):
57.5%-53.3% Stay in Covered California
21.3%-20.5% Take up Medi-Cal/public coverage
19.0%-18.3% Leave for job-based coverage
2.2%-7.9% Become uninsured
Enrollment in Medi-Cal and Covered California will be dynamic as Californians move in and out of coverage and change coverage sources. This policy brief predicts a significant level of churn out of Medi-Cal and Covered California each year. Approximately one-fifth of the cohort of Covered California enrollees are expected to transition to public coverage such as Medi-Cal, and another fifth are expected to transition to employer-sponsored coverage.
Understanding the extent and nature of churn can help in planning for ongoing enrollment, ensuring smooth health coverage transitions and continuity of care, and reducing uninsurance.
* Effective implementation of the changes aimed at streamlining the redetermination processes is required for the stability of the Medi-Cal population to actually increase.
* It will be vital for the enrollment infrastructure — from outreach, to the website, to in-person and call-center assistance — to be available and active even outside of open enrollment periods.
* Making sure that people successfully transition from one type of insurance to another will depend not only on the ease of enrollment, but also the extent to which Covered California and Medi-Cal take advantage of existing institutional points of connection to people undergoing these life transitions, e.g., COBRA notices or government services like unemployment, CalFresh (food stamps), or the Department of Motor Vehicles.
* It will be important that outreach, enrollment assistance, and effective sign up processes are available throughout the year for Medi-Cal and for those who experience life transitions that qualify them for mid- year enrollment in Covered California.
Bouts of uninsurance are known to have negative health consequences. The uninsured have higher mortality overall, and are more likely to go without care. Those who are not continuously insured underutilize preventive care, and have been found to use more care when they do become insured.
One of the fundamental policy flaws with a fragmented, multi-payer system of financing health care is that the eligibility of each individual for various sources of coverage is dynamic – ever changing – requiring movement in and out of various forms of coverage or ending up with no coverage at all. This study from the UC Berkeley Labor Center shows that just the movement out of California’s Medicaid (Medi-Cal) and exchange plans (Covered California) is projected to be considerable during a twelve month period.
About one-fourth of Medi-Cal enrollees will leave the program because of income increases exceeding eligibility levels for the program, or because of becoming qualified for job-based coverage. For the Covered California exchange, almost half will leave because of a decline in income to levels eligible for Medi-Cal, or because of a transfer into job-based coverage, or simply because of falling into the ranks of the uninsured.
When you look at their recommendations to ameliorate the instability of coverage, it demonstrates once again that ACA is increasing the administrative complexity of our system when what we need is the administrative simplicity of a single payer system.
This study does not address the many other circumstances that can result in a change or loss of coverage, especially with employer-sponsored plans. Unstable coverage – churning – can have negative consequences because of disruption of continuity of care such as through your source of primary care, especially if you have or will have a chronic disorder requiring ongoing medical management.
The following paragraph is from a 2008 Quote of the Day (before ACA) that describes a few but by no means all of the reasons for churning. Churning is not a new discovery. Unfortunately, the ACA improvements have only a minimal impact in reducing churning. With the new mandates, eligibility requirements and other ACA provisions, churning may actually show a net increase. Reading this paragraph will once again remind you why we need single payer reform – an improved Medicare that covers absolutely everyone, forever. With single payer, churning is eliminated.
“You may have changed jobs, likely more than once, and lost the coverage that your prior employer provided. Your employer may have changed plans because of ever-increasing insurance premiums. Frequently your insurer introduces plan innovations such as larger deductibles, a change from fixed-dollar copayments to higher coinsurance percentages, tiering of your cost sharing for services and products, reduction in the benefits covered, dollar caps on payouts, and other innovations all designed to keep premiums competitive in a market of rapidly rising health care costs. You may have lost coverage when your age disqualified you from participating in your parents’ plan. You may have found that health benefit programs have been declining as an incentive offered by new employers. Your children may have lost coverage under the Children’s Health Insurance Program when your income, though modest, disqualified your family from the program. Your union may not have been able to negotiate the continuation of the high-quality coverage that you previously held. Your employer may have reduced or eliminated the retirement coverage that you were promised but not guaranteed. Your employer may have filed for bankruptcy without setting aside the legacy costs of their pensions and retiree health benefit programs. You may have decided to start your own small business and found that you could not qualify for coverage because of your medical history, even if relatively benign, or maybe your small business margins are so narrow that you can’t afford the premiums. You may have been covered previously by a small business owner whose entire group plan was cancelled at renewal because one employee developed diabetes, or another became HIV infected. Your COBRA coverage may have lapsed and you found that the individual insurance market offered you no realistic options. You may have retired before Medicare eligibility, only to find that premiums were truly unaffordable or coverage was not even available because of preexisting medical problems.”
By Ross Douthat
The New York Times, March 31, 2014
Back when rate shock, website problems and lagging enrollment were threatening to unravel the new health care law before it fully took effect, I concluded a column on Obamacare’s repeated near-death experiences with the following warning to conservatives:
“The welfare state’s ability to defend itself against reform, however, carries a cautionary message for Obamacare’s critics as well. What isn’t killed outright grows stronger the longer it’s embedded in the federal apparatus, gaining constituents and interest-group support just by virtue of its existence even if it doesn’t work out the way it was designed. And as disastrous as its launch has been, if the health care law can survive this crisis in the same limping, staggering way it survived Scott Brown and the Supremes, then it will be a big step closer to being part of the status quo, with all the privileges and political strength that entails.
“So yes — it’s possible that this brush with death will be fatal, possible that the law will fall with the lightest, most politically painless push. But it’s still likely that Obamacare will be undone only if its critics are willing to do something more painful, and take their own turn wrestling with a system that resists any kind of change.”
With the latest numbers showing exchange enrollment climbing toward 7 million, I think we can safely retire that “possible,” and change the “likely” to an “all-but-definite.” Not because rising enrollment proves that Obamacare is definitely working, in the sense that both its friends and critics would have originally understood the term. We don’t know yet what the paid enrollment looks like or how successfully the program is actually enrolling the uninsured. (After some grim estimates, this Rand study is making liberals feel a little more optimistic, but still suggests a below-expectations result.) We don’t know what the age-and-health-status composition of the enrollee pools looks like or what that means for premiums next year and beyond. We don’t know if any of the suspended/postponed provisions of the law will actually take effect. And we certainly don’t know what any of this means for social policy in the long run.
But we do know that there won’t be an immediate political unraveling, and that we aren’t headed for the kind of extremely-low-enrollment scenario that seemed conceivable just a few months ago, or the possible world where cancellations had ended up outstripping enrollment, creating a net decline in the number of insured. And knowing that much has significant implications for our politics. It means that the kind of welfare-state embedding described above is taking place on a significant scale, that a large constituency will be served by Obamacare (through Medicaid as well as the exchanges) in 2016 and beyond, and that any kind of conservative alternative will have to confront the reality that the kind of tinkering-around-the-edges alternatives to Obamacare that many Republicans have supported to date would end up stripping coverage from millions of newly-insured Americans. That newly-insured constituency may not be as large as the bill’s architects originally hoped, or be composed of the range of buyers that the program ultimately needs. But it will be a fact on the ground to an extent that was by no means certain last December. And that fact will shape, and constrain, the options of the law’s opponents even in the event that Republicans manage to reclaim the White House two years hence.
Such political and policy constraints, I should note, are potentially a good thing for would-be conservative reformers, since the serious right-of-center alternatives to Obamacare have always included policies to expand coverage, and with a coverage expansion accomplished, Republicans may find themselves effectively forced in a more serious direction. (This is a drum that Avik Roy, among others, has been beating for some time.) Or so I would hope; of course, they might just end up drifting toward gimmicky micro-reforms instead, or find themselves embroiled a ruinous civil war over how hard to push toward some kind of full repeal.
But wherever they go and whatever they do, they will have to deal with the reality that Obamacare, thrice-buried, looks very much alive.
==Obamacare, The Unknown Ideal
By Paul Krugman
No, I haven’t lost my mind — or suddenly become an Ayn Rand disciple. It’s not my ideal; in a better world I’d call for single-payer, and a significant role for the government in directly providing care.
But Ross Douthat, in the course of realistically warning his fellow conservatives that Obamacare doesn’t seem to be collapsing, goes on to tell them that they’re going to have to come up with a serious alternative.
But Obamacare IS the conservative alternative, and not just because it was originally devised at the Heritage Foundation. It’s what a health-care system that does what even conservatives say they want, like making sure that people with preexisting conditions can get coverage, has to look like if it isn’t single-payer.
I don’t really think one more repetition of the logic will convince many people, but here we go again. Suppose you want preexisting conditions covered. Then you have to impose community rating — insurers must offer the same policies to people regardless of medical history. But just doing that causes a death spiral, because people wait until they’re sick to buy insurance. So you also have to have a mandate, requiring healthy people to join the risk pool. And to make buying insurance possible for people with lower incomes, you have to have subsidies.
And what you’ve just defined are the essentials of ObamaRomneyCare. It’s a three-legged stool that needs all three legs. If you want to cover preexisting conditions, you must have the mandate; if you want the mandate, you must have subsidies. If you think there’s some magic market-based solution that obviates the stuff conservatives don’t like while preserving the stuff they like, you’re deluding yourself.
What this means in practice is that any notion that Republicans will go beyond trying to sabotage the law and come up with an alternative is fantasy. Again, Obamacare is the conservative alternative, and you can’t move further right without doing no reform at all.
There have been many isolated efforts to define the conservative, or Republican, or libertarian proposal to replace the Affordable Care Act (ACA or Obamacare), but there is no one model that the Republicans wish to advance in Congress at this time. The Republican controlled House of Representatives has voted fifty times to repeal ACA, but they have not voted on any substitute to address the widely acknowledged deficiencies in health care financing.
Conservative Ross Douthat and liberal Paul Krugman now provide us with a perspective on the conservative/Republican alternative for reform.
Douthat acknowledges that a conservative goal is to expand coverage (especially for the more vulnerable), whereas the current “tinkering-around-the-edges alternatives to Obamacare that many Republicans have supported to date would end up stripping coverage from millions of newly-insured Americans.” He suggests that the policy restraints of an ACA already in place would force Republicans “in a more serious direction.”
Krugman, on the other hand, writes, “Obamacare IS the conservative alternative.” Not only does it meet many of the conservative goals of insurance reform, it was even designed by the conservatives. The liberal position would have been to support a single payer model.
Single payer was abandoned in favor of the conservative model that would bring Republicans on board with a new, post-partisan president, while liberals would forfeit the single payer advantages in exchange for a politically feasible, bipartisan accord.
Think of where that puts us now. If the conservatives were to gain complete control, they would tweak ACA to loosen regulation of insurers, to reduce federal funding, and to place greater control within the states. If the liberals were to gain complete control, they would tweak ACA to correct many of the defects that were left in place when the negotiations refining the legislation were halted abruptly because of the Democrats having lost a filibuster-proof majority in the Senate (not to mention the sabotage of a former Democratic vice-presidential nominee).
The fact that further battles will all take place over on the right is a tragedy. The fundamental structure of ACA is irreparably flawed, as would be any modifications that the Republicans would make to move the insurance function further into the private marketplace. Already we have seen a great multitude of very serious flaws that scream out for remedial legislation. But each new patch creates more complexity. The fundamental infrastructure cannot be repaired by patches. We need a new infrastructure (and it would be better and cheaper!).
Krugman says, “in a better world I’d call for single-payer.” Let’s make this a better world.
By Sharon K. Long
BCBS of Mass Foundation, RWJ Foundation, Urban Institute, March 2014
These findings highlight the vulnerability that Massachusetts families experience when faced with high health care costs. Overall, 42.5 percent of all nonelderly adults in the state reported that health care costs had resulted in financial problems or health care access problems for their families in the past year, with the burden greater for low-income adults (46.5 percent for those with income at or below 138 percent FPL) and middle-income adults (53.9 percent for those with income between 139 and 399 percent FPL). Nearly three-quarters (70.6 percent) of those who were uninsured for all or part of the year reported problems with health care costs. However, neither higher income nor health insurance coverage protected Bay State families: 31.7 percent of higher-income adults and 38.7 percent of adults with insurance coverage for the full year also reported that health care costs had resulted in problems for their families.
Health care costs are creating difficult choices for families in Massachusetts. Insured adults frequently reported going without needed care because of costs, cutting back on non-health-related spending to pay for health care, and reducing their family’s financial security to pay for health care, both by reducing savings and by taking on debt, including credit card debt. As a result, medical debt had a significant impact on many families, particularly middle-income families, with contacts from collection agencies quite common.
****Health Insurance Coverage Is Just The First Step: Findings From Massachusetts
By Sharon Long, Kate Willrich Nordahl, Kaitlyn Kenney Walsh, Kathy Hempstead, and Ariel Fogel
Health Affairs Blog, March 26, 2014
The challenges faced by low-income and middle-income Massachusetts families are particularly worrisome given that the consumer protections for out-of-pocket health care costs are generally better in Massachusetts than those required under the ACA. For individuals with family income between 100 and 200 percent of poverty who are enrolled in the state’s subsidized health insurance program, out-of-pocket spending for covered prescriptions and medical services is limited to $1,000 per benefit year. The ACA allows individuals in this income cohort to have out-of-pocket costs that can sum to more than double this amount ($2,250).
The provisions of the Affordable Care Act (ACA) have provided the nation with health care coverage similar to that which has existed in Massachusetts. However, “the consumer protections for out-of-pocket health care costs are generally better in Massachusetts than those required under the ACA.” Though Massachusetts has better coverage, “Overall, 42.5 percent of all nonelderly adults in the state reported that health care costs had resulted in financial problems or health care access problems for their families in the past year.”
Over half of middle-income adults in Massachusetts also “reported that health care costs had resulted in financial problems or health care access problems for their families.”
Furthermore, “neither higher income nor health insurance coverage protected Bay State families: 31.7 percent of higher-income adults and 38.7 percent of adults with insurance coverage for the full year also reported that health care costs had resulted in problems for their families.”
This is the shocking truth about our new national standard of underinsurance: In spite of having greater financial protection than that offered through the Affordable Care Act, over one-half of middle-income adults and nearly one-third of higher-income adults in Massachusetts still had problems with health care costs. And many of those who didn’t have problems likely avoided them by being fortunate enough to remain healthy. That is not the way an egalitarian health care financing system should work.
This ACA turkey won’t fly. All of us, including many of those with higher incomes, would benefit from single payer.
Medical Xpress, March 24, 2014
Spending by Canadians on private health insurance has more than doubled over the past 20 years, but insurers paid out a rapidly decreasing proportion as benefits, according to a study published today in the CMAJ (Canadian Medical Association Journal).
The study, by University of British Columbia and University of Toronto researchers, shows that overall Canadians paid $6.8 billion more in premiums than they received in benefits in 2011.
Approximately 60 per cent of Canadians have private health insurance. Typically obtained as a benefit of employment or purchased by individuals, private health insurance usually covers prescription drugs, dental services and eye care costs not paid by public health care.
Over the past two decades, the gap between what insurers take in and what they pay out has increased threefold. While private insurers paid out 92 per cent of group plan insurance premiums as benefits in 1991, they paid only 74 per cent in 2011. Canadians who purchased individual plans fared even worse, with just 38 per cent of their premiums returned as benefits in 2011.
“Small businesses and individual entrepreneurs are the hardest hit – they end up paying far more for private health coverage,” says study lead author Michael Law, an assistant professor in UBC’s Centre for Health Services and Policy Research, “It’s essentially an extra health tax on one of our main economic drivers.
“Our findings suggest that private insurers are likely making greater profits, paying higher wages to their executives and employees, or spending more on marketing,” Law adds.
CMAJ article (first page, paywall for rest):http://www.cmaj.ca/content/early/2014/03/24/cmaj.130913.extract
Although Canada’s single payer system provides excellent coverage for most health care, a market for private health insurance sprung up to cover prescription drugs, dental services and eye care that were not covered by the original program. The for-profit insurers did what they are expected to do. They began by retaining 8 percent of premiums for administrative costs and profits. But after two decades, they now retain as much as 62 percent of premiums for profits, high executive compensation, marketing and other administrative costs.
Although some are calling for more regulation of Canada’s private insurers, they should have learned from the experience in the United States. No amount of regulation will eliminate their inefficiencies and waste. Coverage for these services should be rolled over into the public single payer system.
Opponents protest that Canada cannot afford to offer these benefits in their public program. Nonsense. Most Canadians are already receiving drugs, dental care and eye care, and it is being paid for out-of-pocket or through private insurance. The money is already being spent; it just needs to be spent better. Placing these benefits into the public program would do the following things: 1) administered pricing would ensure value, 2) financial barriers to care would be reduced, 3) financing would be more equitable, and 3) the excesses and waste of the private insurers would be eliminated.
When we enact our single payer system here in the United States, we’ll need to be sure that we don’t make the same mistakes as Canada, though they are far fewer than our blunders.
The Diane Rehm Show, March 26, 2014
Diane Rehm: Briefly, how do you feel about the Affordable Care Act?
President Jimmy Carter: I was disappointed the way it was done and the complexity that it assumed. Instead of taking a leadership role from the White House and saying, “This is what we think is best,” they had five different congressional committees do it and it got, I think, the lowest common denominator, which is the most complex system. I would really have favored just the expansion of Medicare to include all ages, rather than just to deal with old people.
Video (38 second clip of quote above; also full 51 minute video):http://thedianerehmshow.org/shows/2014-03-26/president-jimmy-carter-call…
Characterizing the Affordable Care Act as “the lowest common denominator – the most complex system,” President Jimmy Carter tells us that he would have favored “the expansion of Medicare to include all ages.”
He’s right, and here’s why. There have been numerous analyses of multiple models of reform. Most of them have included a model that would build on our private insurance system and expand Medicaid, just as is found in the Affordable Care Act. Of these analyses, this is the most expensive model and it falls short on important goals such as universality, equity, administrative efficiency, and affordability.
In contrast, single payer is the least expensive of the effective models and achieves virtually all of the goals of reform. An improved version of Medicare that is expanded to include everyone would be such a model. A health service model – socialized medicine – would also work, but the nation is still too leery of that much government involvement. The popularity of Medicare indicates that this is about the level of government involvement that most would support.
We have to keep reminding Americans that the exchanges are marketing private insurance – not government insurance, so they cannot confuse a government exchange with government insurance. In fact, the exchanges are prohibited from even including a government “public option” (which wouldn’t have worked anyway since the rest of the fragmented, dysfunctional system would have been left in place). Those who defend the private Medicare Advantage plans have to be reminded that they burn up more taxpayer dollars for administration and profits while depriving patients of choice because of their limited networks of providers. Once payment between government Medicare and private Medicare Advantage is equalized, the the private insurers cannot possibly compete with the government program because of their inherent inefficiencies. This was already proven by the failure of the Medicare + Choice plans that preceded Medicare Advantage.
It’s too bad that Jimmy Carter didn’t start talking about Medicare for all when he was president. It might have been helpful if the public had had a few decades to think about it before we got to the point that legislation could be passed. They could have pressured the politicians to do it right.
By Matthew Anderson
Health Affairs Blog, March 17, 2014
Sometime in the past five years — it’s hard for me to say exactly when — I suddenly found myself living in a new home. I must admit I am still a bit disoriented by how this happened. But it did. People keep telling me that everything will be ok but I am not entirely sure.
1. Is this a home or is it a hostel?
2. Will my old friends still be welcome in my new home?
3. Does Mommy love me or is she just paid to say so?
4. Why are we playing computer games during family time?
5. Are there any family secrets left?
6. Everyone tells me how important I am, so why is my allowance being cut?
7. Do I have to go to Church now?
8. Can we get some family therapy?
9. Can’t we afford a better home?
There was a time when family medicine saw itself as a counter-culture in medicine with a mission to incorporate a different set of values. Our job should be to improve the wellbeing and health of our patients and their communities, not the bottom line of the corporations who thrive off our labor.
Such a dream will not happen until health care is seen as a public good instead of a private commodity. A national health system, it seems, is the only economically rational and humane way forward.http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/
What is a patient-centered medical home? To some it means the place you go to get health care – full primary care and a convenient and efficient entry path into more specialized services. To others it means a way of organizing the business of health care to make it more accountable for reducing costs, guided by the dictates of private insurers and government bureaucrats implementing the Affordable Care Act.
Matthew Anderson’s nine questions about the nature of the medical home should serve as a teaser to read the full article on the Health Affairs Blog. It is not simply about the medical home concept, but it questions the whole direction in which our health care system is headed. Not only should you read it, but you should download it and share it with others.
Dr. Anderson has the right values. He is a driving force behind The Social Medicine Portal (An Alternative to Corporate Health) and an editor of the journal, “Social Medicine.”
The Social Medicine Portal: http://www.socialmedicine.org/welcome-to-the-social-medicine-portal/
Social Medicine: http://www.socialmedicine.info/index.php/socialmedicine/index
Repeating his astute words, “Our job should be to improve the wellbeing and health of our patients and their communities, not the bottom line of the corporations who thrive off our labor. Such a dream will not happen until health care is seen as a public good instead of a private commodity. A national health system, it seems, is the only economically rational and humane way forward.”
By Samuel Metz, M.D.
In their recent paper in the Harvard Business Review, Messrs. Porter and Lee make an eloquent argument that their Value Transformation process will reduce health care costs and improve medical outcomes. They could be right. However, this strategy will certainly fail in the U.S. because it addresses delivery of health care, not financing of health care.
This distinction is crucial. Porter and Lee describe an ideal delivery system, addressing how providers are paid for patient care. Their proposal leaves untouched our financing system, which determines which patients participate, who pays, and how we collect.
If we look at successful health care systems, we find that none finance care with our American private insurance business model.
Delivery of health care in the U.S. is not much different from those in successful systems. What separates the U.S. from successful health care systems (i.e., those providing better to more people for less money than we do) is that millions of Americans lack access to any care at all—at least not until the acuity of their deteriorating health drives them to emergency rooms.
Successful health care systems within our country (there are too few) utilize a variety of delivery systems, and many utilize aspects of the authors’ Value Transformation process. However, all have three common financing characteristics not seen in our American financing model: (1) universal access to comprehensive care without discrimination against the sick, poor, or unemployed; (2) encouragement of patients to seek health care without financial penalty; and (3) financing by publicly accountable, transparent, not-for-profit agencies.
A health care system containing all three characteristics but using only one publicly accountable, transparent, not for profit financing agency is called “single payer.” Many single payer systems apply Value Transformation processes in their delivery systems, and with good results.
In contrast, providers practicing in a health care system lacking these three financing characteristics are motivated primarily to avoid sick patients. We see this as private health insurance companies focus on selling policies to the working wealthy only, to the exclusion of the unemployed poor. Mark Bertolini, CEO of Aetna insurance, neatly summarized this strategy: “margins over market.” An insurance executive’s successful health care system starts by including only those patients sufficiently wealthy to afford policies and sufficiently healthy not to need care.
The Value Transformation process can potentially reduce costs and improve outcomes only for patients who gain access to care. Patients without access will continue to embarrass our public health record and inflate our costs by their desperate attempts to get care through emergency rooms; all this despite the Value Transformation process to which they have no access.
There are three rules to create a successful health care system:
1. If you want to provide comprehensive care to more people for less money, reform the financing system.
2. If you want to dramatically reduce costs without compromising quality, reform the delivery system.
3. If you want Rule #2 to work, you must first apply Rule #1.
The critical shortcoming of Porter and Lee’s Value Transformation process is that it reforms our dysfunctional delivery system without first reforming our dysfunctional financing system. There are no examples of any delivery system succeeding in the absence of a functional financing system.
The complete power of Porter and Lee’s Value Transformation process can be enjoyed when (and only when) a reformed financing system allows all Americans to enjoy access to comprehensive care.
1. Michael E. Porter and Thomas H. Lee. “The strategy that will fix health care” Harvard Business Review, October 2013. http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1
2. Kenneth Arrow et al. Toward a 21st-Century Health Care System: Recommendations for Health Care Reform. Ann Intern Med 2009; 150:493-495. http://www.annals.org/content/150/7/493.full.pdf+html
3. WC Hsiao et al. What Other States Can Learn From Vermont’s Bold Experiment: Embracing A Single-Payer Health Care Financing System. Health Affairs 2011; 30:1232-1241. http://content.healthaffairs.org/content/30/7/1232.full?sid=56ce15de-c1b1-4dcf-8ffb-a7b3a09871b6
4. Stephen Kemble. Why Competition Among Health Plans Can’t Help Us. OpEd News, November 17, 2011. http://www.opednews.com/articles/Why-Competition-Among-Heal-by-Stephen-Kemble-111117-858.html
5. Jim Kronenberg. A Conversation with David Lawrence. History of Medicine Project, Medicine in Oregon, Summer 2011, page 20. http://associationpublications.com/flipbooks/oma/summer-11/pubData/source/OMA_Summer2011.pdf
6. T.R. Reid. The Healing of America, Penguin Press, New York, 2009. Chapters 10, 13.
7. Mark Stabile et al. Health Care Cost Containment Strategies Used In Four Other High-Income Countries Hold Lessons For The United States. Health Affairs 2013(4); 32:643-652. http://content.healthaffairs.org/content/32/4/643.full.pdf+html
Dr. Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, both advocates for single-payer health care, and of Health Care for All Oregon, an umbrella organization advocating for publicly funded universal care for all Oregonians.
PNHP note: This article originally appeared at the blog of Health Care Disconnects, an online journal devoted to sharing evidence-based information about problems and solutions to the dysfunctional health care system in the United States.
By Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and David C. Radley
The Commonwealth Fund, March 2014
The twin goals of health insurance are to enable affordable access to health care and to alleviate financial burdens when injured or sick. It is well known that the uninsured are at high risk of forgoing needed care and of struggling to pay medical bills when they cannot postpone care. Studies further find that insured people who are poorly protected based on their households’ out-of-pocket costs for medical care are also at risk of not being able to afford to be sick.
Using newly available data from census surveys, this report provides national and state-level estimates of the number of people and share of the population that were insured but living in households that spent a high share of annual income on medical care in 2011–12. In the analysis, we refer to these people as “underinsured.” However, this group is only one subset of the underinsured. Our estimates do not include insured people who needed care but went without it because of the out-of-pocket costs they would incur, or the insured who stayed healthy during the year but whose health insurance would have exposed them to high medical costs had they needed and sought care.
The analysis finds that in 2012, there were 31.7 million insured people under age 65 who were underinsured. Together with the 47.3 million who were uninsured, this means at least 79 million people were at risk for not being able to afford needed care before the major reforms of the Affordable Care Act took hold.
In all states, people with low incomes are at greatest risk for being underinsured or uninsured. Nationally, in 2012, nearly two-thirds (63%) of those with incomes below the federal poverty level were either underinsured or uninsured. Among those with incomes between 100 percent and 199 percent of poverty, nearly half (47%) were underinsured or uninsured.
A decade or more of people losing health coverage and a steady erosion in the financial protection of insurance has also put middle-income families at risk. In 2012, one of five people (20%) under age 65 with middle incomes (between 200% and 399% of poverty)—an estimated 15.6 million people—were either underinsured or had no health insurance.
Low- and Middle-Income Households Most at Risk
The exposure to high out-of-pocket medical care costs even when people have insurance reflects insurance trends — including higher deductibles and cost-sharing, as well as gaps in benefits or limits on coverage — in both the employer and individual insurance markets. This puts insured families at risk in terms of access to health care and financial well- being. Studies indicate that low- and middle-income insured individuals and families who face high out- of-pocket costs for medical care relative to their incomes are nearly as likely as the uninsured population to go without care because of costs, forgo care when sick, struggle to pay medical bills, or incur medical debt. Both population groups — underinsured and uninsured — are at far higher risk of access or medical bill concerns than those with more protective coverage.
Premiums for Employer-Sponsored Insurance Have Risen More Rapidly Than Incomes, Value of Benefits Declined
Over the past decade, the cost of health insurance has risen far faster than incomes for middle- and low-income working-age families.
At the same time that premiums have risen, the value of benefits has declined. Deductibles more than doubled for plans provided by larger and small employers. This increase — plus other cost-sharing or limits on benefits — has left insured patients paying a higher share of medical bills. With little or no growth in incomes over a decade, insurance and care have become less affordable.
Medicaid and Income-Related Premium Assistance
Using newly available information on out-of-pocket payments for premiums, we estimate that 29 million insured people — 11 percent of the total under-age-65 population and 13 percent of the insured population under age 65 — paid premiums that exceeded the Affordable Care Act premium contribution thresholds for those at their household income level before reforms. In other words, they had high premium out-of-pocket costs compared with incomes, with “high” defined as in excess of Affordable Care Act contribution thresholds.
However, not everyone who pays high premiums relative to income will be eligible for help. The 29 million insured people includes 13.7 million with incomes below 138 percent of poverty who are paying premiums above the Affordable Care Act thresholds for this group. Of these, 8.8 million had private insurance they bought on their own or through employers. Based on their income alone, they would likely be eligible for expanded Medicaid if their state decides to participate in Medicaid expansions.
For those with incomes above Medicaid eligibility, the law restricts eligibility for premium assistance in marketplaces to people buying insurance on their own and to workers who have employer coverage where the employee’s premium costs for self-only coverage exceeds 9.5 percent of income. Among the 29 million insured with high premium costs in 2012, 11.7 million had employer-sponsored coverage and incomes that would be too high to qualify for expanded Medicaid.
Medicaid Expansion Makes a Critical Difference
Many of the states not participating in Medicaid expansion have among the highest rates of uninsured or underinsured people as a share of their total state populations. Without Medicaid expansion, this vulnerable group will remain at high risk for access, health, and financial problems.
Changing the Insurance Map of the Country
Substantial gains, however, will depend on the plans people choose and state efforts to ensure high-value benefit designs and accessible networks. One concern is to what extent people with low or modest incomes will opt for “bronze” level plans. People choosing bronze-level plans will pay 40 percent of medical care costs on average and thus remain at financial risk. Additionally, in choosing a bronze plan, people with low incomes forgo the cost-sharing subsidies that are tied to silver plans that substantially reduce out-of-pocket spending for medical care. As of February 2014, 62 percent of those enrolling in the new marketplaces selected silver plans, 19 percent had selected gold or platinum, and 19 percent had selected bronze.
In addition, it is important to note that the Affordable Care Act’s limits on out-of-pocket costs for covered benefits also apply only to in-network providers. As discussed in a recent report profiling insured people with medical debt, even with the new limits, the insured may encounter high medical care costs if they receive care from out-of-network clinicians.
From the Conclusion
However, the new marketplaces offer plans that include substantial cost-sharing and annual caps on out-of-pocket patient costs that apply to in-network providers only. With these benefit designs, there is the risk that the nation could convert the uninsured into the underinsured and fail to stop the erosion in insurance protections for people with private insurance coverage.
Full report (40 pages – several Exhibits and Tables):
This Commonwealth Fund report provides an estimate of the numbers of underinsured – people who could experience financial hardships and impaired access in the face of medical need. Although the authors express optimism that the numbers of uninsured will decline as a result of the provisions of the Affordable Care Act (ACA), there is a high probability that there will be a substantial increase in the numbers of people who will be underinsured.
The private insurance design features supported by ACA makes continued underinsurance an inevitability. The insured are vulnerable because of low actuarial value plans with high-deductibles and other cost sharing, narrow and ultra-narrow networks that impair access to in-network providers, inadequacies of the subsidies, and the perpetuation of an expensive, administrative wasteful model of financing care – a model that we all pay for, including the underinsured.
What is not expressed in the Commonwealth data is the number of people who may not have attempted to access care because of concerns of high out-of-pocket costs. Studies have shown that these people do forgo care that they should have.
A sobering thought is the even larger numbers of individuals not represented in this study. These are the people who remained healthy and never had to test the adequacy of their insurance. Tens of millions of people are vulnerable and would become financially insecure if they did develop significant health problems. This includes many individuals with employer-sponsored insurance. They are underinsured and don’t know it. Excluding these individuals from the underinsured count results in estimates far below the actual numbers.
The design of ACA makes it clear that both the uninsured and underinsured will remain a problem in the foreseeable future, but it will be underinsurance that will likely provoke widespread discontent. Its prevalence may well become the most compelling reason to abandon the perversities brought to us by the private insurance industry. People will be ready to replace our dysfunctional system with a single payer national health program that would eliminate, for everyone, financial barriers to health care.
Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP)
C-SPAN, March 21, 2014
Karen Ignagni: I would say that what we’ve learned – and I want to go back to this whole transition point – the reason that the decision was made to allow people to stay in their plans is because there was concern being expressed about ten categories of coverage – no matter how meritorious each and every one of those benefits may be – for an individual purchasing, or a small business, sometimes from where they started, which, in general, the old market had very high deductibles – that’s what people preferred to buy because they wanted to keep their premiums low. Then if you take ten categories of coverage and you have a giant step up, well that is a bridge too far for some individuals. And that was being telegraphed pretty clearly in the fall, not from us but from people who were buying the product and would have to spend more. So I would create a lower tier so that people could gradually get into the program, so they could be part of the risk pool so we don’t hold the healthier people outside, so the process could be working the way it was designed, so we get the healthy and the sick. And I think doing things gradually, just from human nature perspective, it just makes more sense.
Marry Agnes Carey: Wouldn’t a lot of healthy people congregate in that lower tier?
Karen Ignagni: Not necessarily. We’re not seeing that right now in the bronze, silver and gold. I think by that hypothesis you would have expected an extraordinary amount of people to buy bronze and they have chosen more silver, which is not as high deductible. So they wanted to lower their deductibles. They’re willing to pay a little bit more per month. But the point is that people are choosing. What I would do is give people more choices. I just… human nature suggests that people like that. They’re in control if they have more choices.
One of the more important goals of health care reform was to require plans to provide comprehensive benefits. Although, as with other compromises in the Affordable Care Act (ACA), the legislation fell short, at least they did require that ten categories of benefits be covered, even if insurers were allowed considerable flexibility within each of the ten categories. Now AHIP – the insurers’ lobby organization – is attempting to dismantle the benefit requirement.Suppose we said that males could decline obstetrical benefits if they wanted to, or females could decline prostate cancer benefits, or non-drug using monogamists could decline HIV/AIDS benefits, or young invincibles could decline all benefits except physical trauma, or whatever, what would happen to the risk pooling function of insurance? Obviously that would violate one of the the most important functions of prepaid health care – pooling all risks. Fragmenting risks into a multitude of pools moves away from prepaid health care for everyone and toward each person becoming responsible for paying for the care they use. At the extreme is requiring everyone to pay full costs in cash. How far along that polarity do we move – moving from bad to worse?
Creating another tier below the lowest current metal level – bronze – meets the desires of insurers who want to expand their markets by offering really cheap plans that exclude major benefits, but it does so at a cost of breaking up the risk pools such that people with expected higher costs are concentrated in comprehensive plans, driving premiums up to ever less affordable levels.
“Erin,” responding on the KHN Blog, suggested that we call this new lower metal tier “pyrite” or fool’s gold.
Look how the insurance industry has manipulated the goals of health care reform:
* We wanted to include everyone, and 31 million people will be left out.
* We wanted to reduce financial barriers to care, and the insurers reduced the actuarial value of their plans by increasing financial barriers to care in the form of deductibles and other cost sharing.
* We wanted to slow total spending to sustainable levels. If that is successful under ACA, it will be accomplished by preventing access to essential health care through limited networks and excessive cost sharing, not through true efficiencies such as are found in single payer systems.
* We wanted to improve quality and instead the insurers sell us more worthless administrative services to play ACO and P4P games.
* We wanted to reduce administrative waste, and instead we add greater administrative complexity through the establishment of insurance exchanges and accountable care organizations.
* We wanted everyone to have comprehensive benefits, and now the insurers bring up the old saw about “giving people more choices” because that puts people “in control” and people “like that.” So let’s strip out their benefits so they can choose cheaper plans that relieve insurers of the pesky need of covering expensive disorders.
Single payer would have achieved these goals, but the insurers keep chiseling away at them to meet their own business needs while sacrificing health care for the people. We can’t seem to fix the insurers, so let’s get rid of them.
(Karen Ignagni said that people are willing to pay more for the silver plans in order to lower their deductibles, but that is not the reason. Since Congress knew that people would select plans with the lowest premiums and thus have grossly inadequate coverage – bronze plans with 60% actuarial value – they prohibited those selecting bronze plans from receiving cost-sharing subsidies for out-of-pocket expenses, forcing them to buy up at least to the still inadequate silver plans with 70% actuarial value. Karen Ignagni knows this, so she was being dishonest by covering it up with the people-liking-choice spin, when all choices are bad – except single payer of course.)