Friday, July 18, 2014

That Was The Week That Was - Issue 19

A look back at the week's health policy news with a focus on ACA implementation


Summer in Maine, where the sun is shining, the birds are singing and health policy activities keep chugging along.  This week a look at the ACA disasters that weren't, more Hobby Lobby fall-out, more Sovaldi developments (look under Drugs below if you don't remember what that is) and as always, much, much more.

ACA: Opposition
We're approaching the midway point between the end of the first open enrollment period and the start of the second.  What better time to pause and look back at some of the predictions of failure.  Paul Krugman (Obamacare Fails to Fail) and Vox (7 predicted Obamacare disasters that never happened) have done just that. 

A senior fellow at the Center on Budget and Policy Priorities notes that Obamacare doesn’t cover media bias. No wonder it’s not more popular., reflecting on law's success lack of impact on public opinion.

Both Ezra Klein (How conservatives won with Obamacare) and Drew Altman (What’s Trending in Health Care? Conservative Ideas.) remind us that based strictly on facts, Conservatives should be jumping up and down with glee over the ACA's success.

ACA: Court Cases (Hobby Lobby, etc.)
More fall-out from the SCOTUS Hobby Lobby decision.  The week started with a look at how A Two-Page Form Spawns a Contraceptive Showdown (providing a look at the details of the exception process that was too onerous).  Then Senate Democrats Launch Fight To Reverse Supreme Court, State Abortion Restrictions with two bills, one a reaction to the Hobby Lobby decision and the second meant to address increasingly restrictive state laws on abortion.  Of course neither has any hope of passing the Senate, let alone passing the House (Democratic Effort To Override Hobby Lobby Ruling Fails), but that's not the point.  Rather, they are part of Democrat's election year strategy: Bills with little chance of passing are part of Congress’s campaign to urge women to vote.

The week ended with one concrete step to assure transparency of employers actions in the wake of Hobby Lobby: White House: Employers Must Disclose Objections To Covering Birth Control.

To be filed under the heading of expected developments, Post-Hobby Lobby, there's been a rapid turnaround in public opinion of the Supreme Court with Poll: Most GOP approve of SCOTUS.  Basically, if SCOTUS makes a decision you agree with, you think they are doing a good job.

Moving on to the pending Boehner lawsuit over implementation of the employer mandate, here are answers to 5 questions about John Boehner’s lawsuit against Barack Obama and a look Behind the GOP focus on Obamacare.

And while Partisanship Infuses Hearings on Health Law and Executive Power, Democrats seek cost estimate of Barack Obama suit. While few expect the suit to gain traction in the courts, we can expect to be hearing about it for a long time to come.

Finally, no recap of court cases would be complete without mentioning the case alleging that the Federal Marketplace can't provide the advance premium tax credits.  So here is a review: How the Courts Could Still Doom Obamacare.

ACA: Marketplaces
The Kaiser Family Foundation released a survey showing that 10.6 million people were helped during the first open enrollment period: Groups Under Health Act Are Said to Aid Millions (Primary source:  Survey of Health Insurance Marketplace Assister Programs).

But there was also more proof that the help was needed for enrollment: Even with Obamacare, shopping for health insurance isn’t as easy as buying a plane ticket and a reminder that once covered, they'll continue to need help understanding the basics of insurance: New challenge for Obamacare: Enrollees don’t understand their insurance plans.

In a startling turnaround, UnitedHealthcare, who did not participate in any Marketplaces last year, announced they will be offering plans on at least half of them this year:  Biggest Insurer Drops Caution, Embraces Obamacare. 

A thoughtful look by Tim Jost on Income Verification On The Exchanges: The Broader Policy Picture (Timmy).  Worth a read as he explores both implementing the current system and how else  it might be structured .

The Feds issued guidance related to how individuals who were terminated for non-payment should be handled during the next open-enrollment period:
CMS has finalized a series of processes and policies regarding enrollment and termination for issuers participating in Marketplaces using the CMS system, including Federally-facilitated Marketplaces (FFM), which include State Partnership Marketplaces. This set of guidance covers topics related to issuers in the individual market regarding grace periods related to terminations for non-payment of premiums coinciding with enrollment in coverage for the next benefit year.
Finally, a look at various state marketplace developments:

ACA: Employers
Although we've seen lots of numbers and analyses on individual enrollment in Marketplace plans, we still know very little about the success (or lack thereof) on the business side (SHOP enrollment): Why we still don’t know how many small businesses signed up through Obamacare - And why it’s probably not very many.

A look at how the Affordable Care Act Oriented Products Will Help Boost ADP And Paychex's Sales - basically employers need help with reporting and will turn to their current vendors for support.

Some continue to ask the question, What will Obama do on employer mandate?  To recap, it was announced earlier that firms with 50-99 FTEs would have until 2016 to begin to offer coverage but those with 100 or more would be subject to the penalty beginning in 2015.  It is unlikely that those broad parameters will change but we're still waiting on final reporting requirements.

ACA: Other
The Commonwealth Fund continues to be busy, this week they issued a report on individual market reforms in each state.  Remember, the ACA provided certain minimum standards for insured health coverage, but insurance continues to be regulated individually by each state so they way those standards are implemented can vary (Implementing the Affordable Care Act: State Action to Reform the Individual Health Insurance Market Primary Source).

Remember the battles over the MLR definition?  No, just me?  OK, to recap, the MLR (medical loss ratio) is the measure of how much of each premium dollar an insurer spends on medical claims.  The ACA imposes minimum standards that if not met, result in rebates being sent to policyholders.  When the regulations were first released, there were arguments over if brokers commission belonged in the calculation or if they should be counted separately.  Currently they are part of the calculation, but if removed it would result in potentially higher insurance company profits (and potentially lower consumer rebates).  Since apparently no decision is ever final, insurers are once again lobbying to change the definition in their favor: How an Obamacare Tweak Could Save Insurers Millions.

Under the category of misleading headlines:  The administration just took Obamacare away from the territories.  Here's the real story - the way the law was originally written, part of the law applied to the territories (insurance reforms such as guaranteed issue) while part (individual mandate, availability of subsidies) did not - you can see how that could cause problems.  Here is an older piece explaining the situation: Think your state has Obamacare problems? They’re nothing compared to Guam.  So what the administration did this week is clarify that since the whole law did not apply to the territories.  A good reminder of how the individual mandate, the subsidies and the insurance reforms all go hand-in-hand.  You can't take away one of the three and expect the others to function as intended.

Medicaid
The administration released its latest figures for new Medicaid enrollment, through may there have been 6.7 million new enrollees:  U.S. Medicaid enrollment nears 7 million since Obamacare rollout.  However, the number should be even higher for two reasons - the first obvious one is that half the states have not expanded Medicaid eligibility, but the second is that in some of the states that have expanded, there continue to be application backlogs.  The feds have had it with Medicaid backlogs and have six states a deadline to come up with plans to eliminate those backlogs.

Need an example of continued waste in the system?  Then you might want to ask Why Are Obstetricians Top Billers For Group Therapy In Illinois? (Hint, there is no good reason.)

Medicare
Did you know that health care is complicated?  This article looks at hospital admissions:  Hospitals, regulators spar over in-patient care policy.  Lots of conflicting interests over the definition of hospital admission vs. observation status.  As is often the case, a lawsuit has resulted - this time creating strange allies of consumers and hospital executives.

VA
Although the House-Senate conference committee continues to meet (to align their respective versions of the bill), Cost debate slows VA reform bill as Lawmakers seek lower price for bill on vets’ care.

At the same time, the Acting VA chief seeks $17.6 billion.  This request, separate from the bills being discussed, muddies the waters: VA request complicates reform push.

The reform bills include increased ability for Veterans to seek care in their community and have the VA pay for it.  Here is a look at the problems involved with that approach, including with the HERO program that is being piloted in Maine: Veterans' Needs 'Should Drive Where They Get Their Care'.

Drugs
Sovaldi continues to be in the news.  That's the Hep C drug that was recently introduced at the price of $1,000 a pill (and $84,000 for a course of treatment).  The prevalence of Hep C, the stunningly improved results with the new treatment and the treatment's cost lead to the inevitable question:  How do you pay for a drug that costs $84,000?

Many think the price is too high (Poll: 4 in 5 say $1,000-a-pill drug cost ‘unacceptable) and some states are moving to limit access to the treatment (Oregon moves closer to limiting access on hepatitis C drugs as Senate investigation begins).  More widely the question is Will Gilead’s Hepatitis C Drug Bust State Budgets?

Congress is looking at the issue.  We've all heard the drug company line that these high prices are needed to recoup the high cost of research. While that argument ignores the fact that much of the basic research continues to be paid for by the Feds, in this case we have a more pressing question.  Gilead, the current producer of the treatment, actually bought the fully developed drug when it purchased the drug's developer.  In the purchase documents filed we see that
"Pharmasset, the drug's original developer, priced the treatment at $36,000, the senators wrote, citing documents filed with the Securities and Exchange Commission. Gilead acquired Pharmasset in 2012 for $11 billion." (U.S. senators ask Gilead Sciences to explain high cost of hepatitis C drug)
Stay tuned, this issue will be around for a long time.

Interesting results from a study that show Changing a pill's color has big health consequences. It's the little things - if you move someone to a generic drug, and the pill looks different, compliance with taking medications goes way down.

Also a reminder that we're not always getting the most appropriate treatment.  Asking the question  Why are doctors still prescribing Zetia?  "The author concluded that it must be that the manufacturer (Merck) has been very effective at marketing ezetimibe and that patients’ and doctors’ fixation on reducing the cholesterol numbers has made it attractive in defiance of its lack of efficacy."

Costs
New CBO deficit estimated brought renewed attention to the fact that those estimates of future health care costs are falling.  While the headline highlighted that the budget deficit was still going to be a problem (CBO: Slowing health-care costs yield big savings, but not enough to bring down our big debt) the numbers are startling. 

Are Hospitals Responding to a Health Reform That Hasn't Happened Yet?  That's one theory as to what's happening.  But perhaps the most honest appraisal came ""At a Tuesday meeting of health economists in Washington on the subject, Uwe Reinhardt, a Princeton professor (and occasional Upshot contributor), cautioned against over interpreting the recent good news.  “We don’t know what the hell is going on,” he said at the Altarum Symposium on Sustainable U.S. Health Spending." (emphasis added, Expected Health Spending Declines (Again)).

But of course that doesn't mean we don't still have cost problems.  Take proton beam therapy, no really, take it and hide it as if it didn't exist.  We know that it is no more effective than older treatments that cost half as much. Using the new Medicare database, an analysis was done as to how much money the treatment is wasting:  Prostate Cancer Treatment: Unproven Proton Radiation Therapy Wastes Millions of Dollars - The High Price of Unnecessary Treatment.  And speaking of wasting money, non-profit hospitals continue to pay exorbitant CEO, and ex-CEO salaries: At NewYork-Presbyterian Hospital, Its Ex-C.E.O. Finds Lucrative Work.

Finally, in the interests of showing all sides, I offer this link to a NY Times piece stating Why Improving Access to Health Care Does Not Save Money.  I disagree with the authors conclusions and have problems with how he reaches them.  He states you can't improve access, quality and cost and still save money.  I think that is wrong.  Very simply, we know from multiple sources that cost and quality are not correlated.  Thus we can provide more high quality care using less money than we are currently spending - thereby freeing up funds to pay for increased access.  The authors inability to understand this basic fact, coupled with his incomplete understanding of the use of emergency rooms by the newly insured (yes, use goes up initially but then falls off in subsequent years) negates his conclusions.  The piece appears in a relatively new section of the Times called "The Upshot".  And while it is clear to me this is an opinion piece, it is not so labeled potentially leading people to assume the author knows what he is talking about.

System Transformation
Nurses and nurse practitioners getting some love in the news this week (as they should every week).  Their importance in our current system and in making that system better can't be overstated.  Take a look:

Also getting attention is the concept of seeing a doctor on-line (or some other remote method).  While Convenience, fixed prices boost demand for doctor visits via Web, text some are concerned - More doctors are a click away, but some say it’s not a healthy trend.  My take, inevitably this will be one path to care - it can help in many cases.  The key will be the on-line providers knowing when to send the patient elsewhere and the use of a universal EHR so that any treatment received is known to the all of the individuals providers.

More proof that economic status is a key determinant of health status, surprisingly even more so than pre-natal drug exposure: 'Crack baby' study ends with unexpected but clear result.

I could do a weekly blog just on the topic of patient safety - since I don't it's lucky others focus on the topic.  This week over thirty patient advocacy organizations and activists asked Congress for an increased focus on the topic: Launching Today: Patient Safety Call to Congress

How do we tell the quality of a provider?  It is not easy - here is an excellent high level review of the issues involved: It’s very difficult to assess a doctor’s true skill or performance.

And finally, a look at the common warning not to go to a hospital in July when the new residents are starting.  Interesting results, while the new residents potentially do have an impact, July is still a safer month than most to be treated in a hospital (despite the misleading headline): The July effect is real: new doctors really do make hospitals more dangerous.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!
Funded by support from the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
Posted by at