That Was The Week That Was - Issue 25

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

This week we saw the release of new contraception rules for some employers, the appointment of a CEO for healthcare.gov , Medicaid expansion developments everywhere but here in Maine, more good budget news re Medicare, and as always, lots more.

ACA: Polls/Opposition

Remember last week when we talked about how Senator Pryor's new commercial (talking about the ACA but not mentioning it by name) was going to change the political landscape?  Well there are as many opinions about what's going on as there are fish in the sea... From Why that one Democratic Obamacare ad didn’t signal a new trend to Democrats Are (Slowly) Learning to Love Obamacare to The Word on Obamacare: It’s Shrinking as a Political Issue. Why so many views, the short answer is it's complicated. There is still a general lack of knowledge as to what the ACA is, couple that with a segment of the population that will reject anything supported by our President and you can see why confusion reigns.

I'll leave this topic with one more (scary) example: " Only 37 percent of the public understood that people shopping in the new health insurance marketplaces could choose from a variety of private plans."  (Obamacare doesn't poll well. So why is an Arkansas senator running on it?)

ACA: Court Cases

While we had no new court rulings this week, there was still lots of activity. Most of it stemmed from the release last Friday afternoon(8/22) of new rules to address providing birth control to employees at both non-profit religious organizations and some closely held for-profit firms: Administration Proposes New Health Rules Addressing Religious Objections.

For details on the new rules, here is an FAQ from Kaiser (FAQ: Administration’s New Contraception Rules Explained), a CMS Fact Sheet (Women’s Preventive Services Coverage and Non-Profit Religious Organizations) and a review and explanation from Tim Jost (Implementing Health Reform: New Accommodations For Employers On Contraceptive Coverage).

Does this mean the end to the controversy?  Probably not. While the New Birth Control Rules Appear To Track Supreme Court Suggestion, one author takes the view that some employers won't go for the accommodation because it means their employees still get birth control: Nice Try, Obama  - The president’s latest accommodation to the contraception mandate has one problem: Religious employers won’t go for it.

Meanwhile, on the subsidy case front, here is a detailed look at the petition for the DC Court to reject the Administration's  en banc request: Republican Lawyers' Latest Sneak Attack on Obamacare Is Their Most Brazen Yet -

And finally on the court front, the news that the House to spend $350K on Barack Obama lawsuit because our Federal budget had an extra three hundred and fifty thousand dollars lying around that they wanted to flush down the toilet.

ACA: Premiums/Costs

More states reporting out their Marketplace rates for next year. Good news both in Arkansas (Health-care premiums fall in Arkansas) and Maryland (Md. approves smaller rate hikes for CareFirst, lowers rates for 3 others).

ACA: Marketplaces

As of Tuesday afternoon, There’s finally someone in charge of HealthCare.gov. The Leader of Connecticut’s Health Marketplace Is Named to Run Federal Program. You'll remember that one of the reasons cited for healthcare.gov having so much trouble was that there was no one person in charge, now there is. You can get to know him here: An interview with Healthcare.gov's new chief executive. While it's indisputable that this was a needed step, there be dragons ahead, as one observer put it: Better Late Than Never: Obamacare Gets a C.E.O. - He worked wonders in Connecticut. But D.C. is a different beast.

Also related to the Federal website, a government audit was released that show How you end up spending $800 million on HealthCare.gov.

A study from the University of PA shows that State sites outperform U.S. marketplace in Affordable Care Act signups - no surprise here as we know that the states that created their own exchanges were more involved and had additional funding streams.

Meanwhile, all is not rosy on the state marketplace front.

In DC we see that Even a Harvard-educated lawyer has ‘nightmare’ with D.C. health insurance site . But as noted in the article: " The correct lesson to draw is that government needs to place a higher priority on efficiency and customer service. Otherwise, a jaded public will give up on extending benefits that people need, such as universal health care, but that the private sector can’t or won’t provide."

The Federal audit moves forward of the Maryland state site: Federal auditors sought documents related to troubled Md. health exchange launch. And in Oregon, the second shoe drops. Remember a few weeks ago, Oracle sued the state. Now Oregon sues Oracle over failed health care website.

ACA: Employers

We haven't heard much about the SHOP (small business marketplace) this summer. Remember many states did not introduce one last year and the Federal one had severely limited functionality (employers could not use it to enroll). This review looks forward thinking that Health Law May Benefit More Small Businesses In The Fall as more states and the Feds get themselves together. But read that piece with a dose of skepticism, we still have not been given a date when enrollment will be available on the Federal SHOP.

And for those questioning if the employer mandate is really going to go into effect (it's supposed to start for those with 100+ employees Jan 1) signs that the government is serious this time as the IRS releases O-Care employer mandate guidance after long wait.

ACA: Other

An in-depth reminder that while in the post-ACA world consumers have a lot more protections, there are still ways for insurers to game the system: 3 ways insurers can discourage sick from enrolling. The public and the advocacy community has to remain on-guard for these potential abuses.

And a reminder that while you can't be charged more if you go to an emergency room that is out-of-network,  if you are admitted and it is an out-of-network hospital, you would have to deal with the out-of-network in-patient charges: Beware Of Higher Charges If You Go To An Out-Of-Network Emergency Room.

As most of you reading this already know, the premium subsidies offered through the marketplace are actually advanced tax credits. That means there will be a reconciliation when you file your taxes. For the 2014 plan year, that will come in early 2015. It's worth remembering that Early tax planning may be needed because of the Affordable Care Act. And if you have not been diligent about updating your financial information on healthcare.gov, Tax refunds may get hit due to health law credits.

One part of the ACA that has not received much attention before now is The obscure part of Obamacare that takes on executive pay. That changed this week as a report was released that showed $72 million has been taken in so far under this provision (Obamacare has a CEO tax — and it just raised $72 million).

We'll conclude this section with a local note, as we received word that Mega insurance company no longer doing business in Maine. While they were not selling plans on the marketplace, they continued to offer off-marketplace individual and small group products. I was somewhat restrained in my public comments (quoted in the article), but my bottom line reaction to the news was yippee!  To call their products health insurance, gives all health insurance a bad name.

Medicaid

Several states saw significant Medicaid expansion news this week, none more impactful than PA while due to the deal reached between their Governor and CMS, 300,000 people will be newly eligible for coverage: Pennsylvania’s GOP governor will expand Medicaid to 300,000 poor people.

Now we have to take a step back and understand what is and is not happening there. First of all, although the state originally asked for 24 waivers from CMS, only 4 were granted. Most importantly, the work requirement they wanted as a condition of eligibility was not allowed (Pennsylvania is expanding Medicaid. Here's how.).

It's also worth noting that while some headlines said Pennsylvania to Purchase Private Care for Its Poor , that's a bit misleading. This is NOT a private option plan (similar to Arkansas). This is having the individuals enrolled in Medicaid Managed Care plans (as previously eligible residents of the state already were using).

Finally, regarding PA I'll note that Corbett is currently in a re-election battle (and behind in the polls). His Dem opponent has said he prefers straight expansion to the form just approved, so it remains unclear what will actually happen there. Although at least we know people will gain coverage.

In Wyoming a Republican administration is also moving forward towards expansion, realizing it made no sense to continue to forgo the federal funds: Another GOP state may be signing up for Medicaid, and the reason is obvious.

In Arizona Medicaid appeal to be heard by court as Gov. Brewer continues to try and move forward with implementation there.

In Tennessee, Gov. Haslam says Medicaid expansion proposal going to feds soon.

And finally, with no movement in sight here in Maine, a reminder from Sara Gagne Holmes that Expanding Medicaid is good for the economy, health of Maine.

Medicare

Starting off with some good news, Yes, Obamacare is cutting the deficit. " The difference between the current estimate for Medicare’s 2019 budget and the estimate for the 2019 budget four years ago is about $95 billion dollars. That sum is greater than the government is expected to spend that year on unemployment insurance, welfare and Amtrak — combined."  (Medicare: Not Such a Budget-Buster Anymore).

Last week we discussed an analyses saying the Medicare Advantage plans might finally be delivering better outcomes. This week a rebuttal taking the position that No, We Still Don’t Have Proof That Private Medicare Plans Are Better.

A caution about the way Medicare rates nursing homes: Medicare Star Ratings Allow Nursing Homes to Game the System.

And a caution about the ACO hype... " The PGP demonstration, which used a payment model similar to the Medicare Accountable Care Organization (ACO) program, resulted in small reductions in Medicare expenditures and inpatient utilization, and improvements in process quality indicators. Judging from this demonstration experience, it is unlikely that Medicare ACOs will initially achieve large savings. Nevertheless, ACOs paid through shared savings may be an important first step toward greater efficiency and quality in the Medicare fee-for-service program." (Financial and Quality Impacts of the Medicare Physician Group Practice Demonstration).

VA

Several developments regarding veterans this week. Starting with some result from the VA investigation stating that the deaths in Phoenix were not caused by the waiting list issues: Probe: No Proof VA Delays Caused Phoenix Veterans To Die.

The President discussed more of the changes that have been ordered in the system: Obama orders aimed at VA delays.

A fascinating story that is sure to get the black helicopter conspiracy folks excited as New Obama plan calls for implanted computer chips to help U.S. troops heal. This is real science that has the promise of incredible benefits, as long as we can get past the headline.

And finally, a story I'm including for multiple reasons: The Number Of Homeless Veterans Really Is Falling. Homelessness is an important factor in health care, so it falls within the range of topics covered here. But additionally I wanted to share because I consider this reporting at its finest. The author takes a government report of good news and tests the data to make sure it's true - and finds that it is!  (Primary Source: HUD, VA, AND USICH ANNOUNCE 33% DROP IN VETERAN HOMELESSNESS SINCE 2010)

Drugs

The ethics of who should get an experimental drug and when they should get it are discussed in this fascinating  review of the Hardy case: " We discuss several issues raised by the Hardy case, including the overarching question of whether it is fair for social media or influence of any form to play a role in determining which patients get access to experimental treatments; whether rescuing individual patients in need can be reconciled with an evidence-based regulatory approval process for new therapies; and whether there is a duty to “rescue” terminally ill patients by paying for access to experimental therapies." (Rescue Me: The Challenge Of Compassionate Use In The Social Media Era)

Meanwhile, across the country continued focus on opiate addiction in all its many forms. First, Chicago and 2 California Counties Sue Over Marketing of Painkillers. Andhere in Maine Once-a-month shot that blocks high from opiates making inroads in Maine.

Costs

It's not often I find myself agreeing with a surgeon about health reform, but to the author of this article, I want to give a heartfelt amen: Robots and health costs: Can either be tamed?

And under the heading of what's old is new again, house calls are back: Study: House calls for frail elderly save money.

And finally, a interesting and practical interim solution for getting our countries health care costs under control quickly: The 125 Percent Solution: Fixing Variations In Health Care Prices. But if you think it's going to happen any time soon, I have a bridge for sale in Brooklyn you might be interested in.

System Transformation

An individual's health is determined by a lot more than what goes on in a doctor's (or provider's) office. This week a review of various studies on The Relative Contribution of Multiple Determinants to Health. Sadly we know that one of those determinants is race. "Even when you control for education and income, black people still fare more poorly than white people, and he thinks one key cause is everyday racism." (White privilege is the best medicine).

The ACA helped give more people coverage for mental health services, but we know that access takes more than coverage, it takes providers: Expansion of Mental Health Care Hits Obstacles. In CA, one response is Urgent Care Centers Opening For People With Mental lllness  "Mental health urgent care centers, also known as crisis stabilization units, are opening throughout California in response to the shortage of psychiatric beds and the increase in patients with mental illnesses showing up at hospital emergency rooms with nowhere else to go, experts and advocates said. In Los Angeles County, four such centers have opened and several more are planned."

Speaking of having enough providers, here is one physician's perspective on use of various types of providers based on real world experience, instead of being based on protecting "turf": Doctors and nurse practitioners: We’re failing the reality test.

Under the heading of making progress, after last week's scary letter to Oregon from the Feds, the Feds back down from directive that undermined Oregon Health Plan reforms. I believe the technical term for my reaction to this news is "phew!"

A physician looks back at some lessons from medical school that still guide him. All I can add is these apply much more broadly than to just the practice of medicine: 4 things I learned in medical training that still apply today.

And finally for this week, we'll end with pieces the deal with the end. First, Operator? Business, Insurer Take On End-of-Life Issues By Phone - While far from ideal, but as one person put it in the article: "“Would I prefer that we live in a health care systems where doctors, nurses, nurse practitioners and social workers who knew the patient were having these conversations? Yes,” he says. “This is better than what patients have currently been getting.”"

Even if you deal with these issues all the time, you don't always know what you don't know: 7 assumptions about end of life care. And furthermore, even if you think you are prepared and doing everything right, that is no guarantee your wishes will be carried out: DNR/DNI: More code than status.

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 24

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

This week a reevaluation of the role the ACA will play in this year's election, diverging views on the role of employers in the future of health care, Medicare makes a revolutionary addition to their reimbursement strategy, plummeting teen birth rates, medical data security and as always, much more.

ACA: Polls/Opposition

Interesting developments this week regarding the approaching elections and how the ACA is portrayed. First we have this take by The New Republic: This Is How Democrats Win on Obamacare - "But people’s feelings about the health care law are complicated. Whatever the attitudes of American voters towards “Obamacare” per se, large majorities seem to approve of what Obamacare actually does. They like the idea of making sure anybody can get insurance, regardless of income or pre-existing conditions. They want to make sure policies are reasonably comprehensive, so that people with insurance don’t still face financial ruin. Sometimes they even like the law as a whole, as long as they don’t associate it with the president."

But wait, there's more (while I usually try not to provide repetitive links, in this case I think it's interesting that so many are saying the same thing): Morning Plum: Obamacare disappearing as major issue and Obamacare Fades Right on Schedule and Obamacare Losing Power as Campaign Weapon in Ad Battles.

What's gotten everyone talking about it is the add being used by Senator Pryor of Arkansas touting his support: From a vulnerable red state Democrat, a strong pro-Obamacare ad.

Some good news on the "price" of health care - but remember, cost is a lot more than price so this is only one piece of the puzzle: Good news for Obamacare: Health coverage is soaring, but health care prices aren't. (When we talk about the cost of health care we consider not only the unit price but also the quantity of units and the mix of services that make up the units.)

ACA: Court Cases

Another quiet week on the court front but we did see Obamacare Opponents Who Won On Subsidies Ask SCOTUS To Take The Case. Their motivation is to get the issue onto the Supreme Court docket before events progress to the point where SCOTUS might not take the case (as is possible if the en banc review reverses the original decision).

ACA: Premiums/Costs

We continue to see more proposed rates dribble out from the states. PriceWaterhouseCoopers continues to track developments. Using that information, here is a look at the changes and a discussion of the variability both based on the state and based on who is "spinning" the numbers (remember numbers on the map are pre-subsidies): Here's What's Going On With Obamacare Premium Increases .

And from the Association of Health Care Journalists (yes there is such an organization, no I am not a member) a primer on how to understand rate increases - as useful for understanding the articles as it is for writing them How to understand 2015 exchange plan insurance rate changes.

ACA: Marketplaces

Can you feel November and the beginning of open-enrollment getting closer? Certainly those who will be working on enrollment can. CMA issued a bulletin (CMS Enrollment Assister Bulletin: 2014-01) and updated their resource page: CCIIO In-Person Assistance in the Health Insurance Marketplaces. At the same time, the Georgetown Policy Institute updated their resources: Navigator Resource Guide Helps Answer Consumers’ Questions about Health Insurance & Coverage.

We've talked before about how some individuals don't need to wait for open-enrollment to enroll in plans, Enroll America released a report estimating that there are 7 million of them out there: Study: 7 Million Could Get Affordable Care Act Coverage Outside of Open Enrollment.

More talk about adding another plan level to the marketplace offerings, a "copper" plan. The problem with this idea is that it would cause problems for those who purchased them not be able to pay their deductibles and copays - the plan would only have an actuarial value of 50% (as compared to the Bronze 60%, Silver 70% and Gold 80%): 'Copper plans' could cut subsidies, lower deficit, but would consumers bite?

Matching the success of the first open-enrollment won't be easy. First a look at CA learning from its mistakes the first time around with respect to its Latino population: Hurdles Remain to Signing Up More Latinos for Health Coverage.

And a look at Alaska where there are issues concerning the underfunding of the Indian Health Service and the difficulties with trying to get ACA coverage to help fill the gap: The trouble with trying to sign people up for health insurance when care is already free.

ACA: Employers

The future role of employers was another hot topic this week, unlike the repetitive articles regarding the ACA and elections, here are several conflicting takes on the issue.

We start with a helpful overview of the role of employers in health care from The Economist: Paternalism 2.0 - American employers are rethinking their role in workers’ health care. Next up some thoughts on how the law is freeing people to make decisions on their jobs independent of decisions on health coverage (the end of job lock). " But just because the ACA may encourage some people to leave their jobs does not mean that “Obamacare is a job killer,” as some political operatives have put it. People who leave their jobs once they are able to find health insurance elsewhere, do so voluntarily. The law is not forcing anyone to stop working. And by leaving the labor force, those Americans open their jobs to others who are hungry for the work." (How the Affordable Care Act might transform the labor market - ).

Then there are those who focus on the mandate pushing people to accept employers' offer of insurance, as it was meant to do: Why More, Not Fewer, People Might Start Getting Health Insurance Through Work, And finally, from Brookings the perspective that the true answer to the Hobby Lobby decision is taking the employer out of the equation completely: Bye, Bye Employer-Sponsored Health Insurance?.

A survey showing that while the health care continues to be important to small employers, it's not the biggest thing on their minds anymore: - "Conversely, health care, which has been one of the most controversial political issues for small firms in recent years, has fallen to fourth on that list, now behind immigration issues and income inequality (the economy was first)." (Small business owners aiming to unseat incumbents in midterms, poll shows ).

ACA: Other

I try to break this publication into sections so that people can focus on their interests. The problem with that is that many topics cut across categories. These first two items could have been under the Marketplace section, but they also apply to health coverage in general, regardless of where it comes from. First, 5 reasons health insurance didn't pay your bill (some useful reminders about how insurance works) and second, HMO, PPO, EPO: How's A Consumer To Know What Health Plan Is Best? (reviewing the basics of different plan types).

Advocates sent a letter to CMS about potentially discriminatory plans: Patient Advocates Say Insurers Avoiding the Sick. While we need to stay vigilant, and there is no doubt some abuse going on, we have to separate those problems from issues of plan design and actuarial value. (Remember the tradeoff between premiums and cost-sharing means that some plans require higher cost sharing until the out-of-pocket maximum is met.)

Another area where we need to separate ramifications of plan design from malicious practices - narrow networks. While they aren't inherently bad, they are different and represent a choice that must be reached with full information resulting from clear communications. In this case it seems like the information needed was not provided by the plan: Anthem Blue Cross sued again over narrow-network health plans.

Continuing the theme, Some Insurers Refuse To Cover Contraceptives, Despite Health Law Requirement. Here it's a clear case that the insurers need reminding about the specifics of law.

And it's not only insurers, some employers need reminding about what they are allowed to do as well. We saw this as the First Wellness Program Firing Suit Filed by U.S. Agency occurred. Remember, wellness programs can be helpful (whether they save money is another question) but they also have a great potential for employer abuse.

And finally, Hospitals Reconsider Charity For Patients Who Decline Health Coverage. We saw talk of this here last year although no changes have yet been made in Maine.

Medicaid

The Center on Budget and Policy Priorities issued a report telling you everything you always wanted to know about the private option expansion waivers but were afraid to ask: Approved Demonstrations Offer Lessons for States Seeking to Expand Medicaid Through Waivers -

Also this week, a problem in Oregon we'll be watching closely: Oregon health reforms threatened by new federal directive, officials say. The whole point of the Oregon waiver was to allow new ways of providing care, if not changed the most recent letter from the Feds would be a big step backwards. (The short version of the waiver is that Oregon wants to be able to buy an asthmatic an air conditioner for $300 to avoid a $3,000 (or more) hospital stay, the government said yes but now seems to be backpedaling.)

Medicare

Lots on the Medicare front this week. Starting with the announcement that Medicare to Start Paying Doctors Who Coordinate Needs of Chronically Ill Patients. This is big - for the first time Medicare will pay not for a specific treatment but for the time it takes to keep the chronically ill well.

An intriguing look at Medicare Advantage plans: Medicare Advantage Is More Expensive, but It May Be Worth It. I'm not convinced, but if true we need to find a way to pay for providing those benefits to all Medicare recipients (remember, Medicare Advantage cost the Feds more than straight Medicare).

At the same time, we know there is money in the system that is not being used effectively. Once again we see that Pervasive Medicare Fraud Proves Hard to Stop. And a look at the history of one of the most prevalent scams - motorized wheelchairs (remember the Scooter Store) - now thankfully under control: A Medicare scam that just kept rolling -

We saw last week that the new website showing provider payments had hit a problem. Now the Doctor Payment Website Is Back on Schedule After Bogus Data Are Discovered. However; Government Will Withhold One-Third of the Records from Database of Physician Payments. Given all the criticisms of the database - including its very existence - the Feds want to make sure the information they do post, even if incomplete, is correct

Kaiser released a comprehensive look at the Medicare Part D program and how it's evolved: Medicare Part D in Its Ninth Year: The 2014 Marketplace and Key Trends, 2006-2014.

Meanwhile, another look at the plan over time shows the plans may be stumbling: "...forgoing basic needs to pay for drugs. Close to 9 percent of beneficiaries reported doing that in 2005; by 2009, only 4 percent did. But in 2011, the proportion climbed back to 5.3 percent — a statistically significant change" (Part D Gains May Be Eroding). Note that this article doesn't mention the closing of the "donut hole", made possible by the ACA, and the impact that will have going forward.

Drugs

It's hard to talk about prescription drugs without talking about money - First a look at an issue over the naming of biologics - will the new "generic" versions be able to have the same name as their therapeutic equivalents (A drug naming dispute, with billions on the line)?

Speaking of money, several years ago the FDA sped up its approval times for new drugs. But along with the speed-up we now see there has been an increase in the need for "black box" warnings: The Role Of Black Box Warnings In Safe Prescribing Practices.

And it's not just the pharmaceutical companies, it can also be providers who are profiting from drugs (and thus possibly having a conflict of interest in what they prescribe): Oncologist pay and chemotherapy: Buy and bill needs to stop.

Finally, because a week can't go by without a Sovaldi story here is a perspective that says we don't need to restrict the number of prescriptions, we need to expand the number: Waging War on Hepatitis C

System Transformation

Lots of attention on falling teen birth rates. And we don't just mean a slight decline, we're talking a dramatic drop as in the teen birth rate has fallen 57% since its peak in 1991. First the numbers: Five fascinating charts on the plummeting teen birth rate. Last week we talked about one state that had a private benefactor pay for birth control (How Colorado’s teen birthrate dropped 40% in four years), this week the media has widened its focus (in the wake of new CDC numbers) to look at the whole country: The historic and uneven decline in teen births.

Conflicting views on why this is happening. First from Sarah Kliff: The mystery of the falling teen birth rate. She looks at various reasons why this may be happening. From another perspective, it's not that complicated: Give Teens Access to Birth Control and, Amazingly, the Teen Pregnancy Rate Drops although this argument seems a bit simplistic to me.

Also, in light of a the announcement this week of a data breach impacting Community Health Systems (4.5 million records in 206 hospitals in 29 states - Chinese hackers may have stolen your medical records) there was a renewed focus on health data security: Health care data breaches have hit 30M patients and counting.

Kaiser provided this FAQ: Are Your Medical Records Vulnerable To Theft? as the FBI warns healthcare firms they are targeted by hackers.

Meanwhile, while healthcare.gov does not contain any medical records, in a related story the US won't reveal records on health website security .

This is all going on during a period when the use of electronic information is only going up as Hospitals must help patients access digital records — or else. (This is the implementation of stage 2 of the meaningful use standards - and if you think stage 1 was hard, it was a walk in the park compared to stage 2.)

While everyone enjoys watching their friends get doused in ice water, It’s going to take a lot more ice buckets to fill the NIH funding gap - the campaign alone is not going to solve the NIH funding cutbacks: " NIH says its budget has effectively been cut by 22 percent in the past decade when accounting for medical inflation" and the s sequester didn't help ("the sequester's automatic 5 percent cut to the NIH resulted in 8 percent fewer research grants in the 2013 fiscal year compared to the previous year")

While police forces doing the wrong thing have been (appropriately) dominating the headlines, some police forces are doing the right thing: San Antonio Police Have Radical Approach To Mental Illness: Treat It. Not only does this yield a better outcome for all involved, it saves money too.

Two reminders that solutions to long standing problems don't need to be complicated. In the first case, Simple measures made hospital patients 70% more likely to quit smoking. And the second shows that One way to boost organ donations: Just keep asking.

On the vaccination front this week, data showing Why States Should Aim For 100 Percent Vaccination. And a reminder that it's not just small children - there are vaccinations that teenagers need including the HPV one that is being grossly underutilized: Let’s Not Talk About Sex.

More on the OpenNotes movement (allowing patients to see their full medical record): "Ninety-nine percent of the patients wanted OpenNotes to continue, and no doctor withdrew from the pilot. Instead, they shared anecdotes like mine. When patients see their records, there's more trust and more accuracy." (When Patients Read What Their Doctors Write)

NPR had a great interview where a Cardiologist Speaks From The Heart About America's Medical System. While the interview is broad, at the end he touches on end of life care. Also on end of life care, the Washington Post continued it's series on hospice coverage by looking at the dangers associated with the rise in for profit hospice providers: As more hospices enroll patients who aren’t dying, questions about lethal doses arise. And speaking of for profit hospice providers, here is a useful FAQ: End-of-life care: An industry with soaring profits, funded by taxpayers. But to be clear - hospice is often an appropriate approach and can be a blessing for both the patient and family. However recent trends in the industry seem to have lead to an increase in the rate of misuse of the concept as well as outright abuse.

It's also worth remembering that it's not just the profit motive that leads to improper decisions. Sometimes we just don't want to let go: Food and the Dying Patient.

And finally, on a subject near and dear to my heart - the need to have a true health care system. A look at how one piece of that would be Incorporating urgent care into the medical home. While new and innovative ways to provide care are helpful (we've looked at some in past issues) they need to be part of a coordinated continuum of care.

Thanks for reading!

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 23

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

We have finally hit the summer slowdown everyone has been expecting so this may be my shortest issue yet.  Of course given the length of some of my updates, that's not saying much.  This week we look at some new made up criticism of the ACA, Marketplace developments including notices requesting additional paperwork from some enrollees, new Medicaid enrollment figures, the latest installment of Dr. House of Cards and as always much more.  So here we go...

ACA: Polls/Opposition

As time moves on, opponents of the ACA continue to have a hard time saying it's failing - not that things are going perfectly by any stretch of the imagination, but there is no denying that millions of people are receiving healthcare today who did not have access last year.  Or is there?  Investor's Business Daily published an article saying that the number of people covered was falling dramatically: ObamaCare Enrollment Falling Significantly, Insurers Reveal.  The problem is they basically made up the story by comparing apples and oranges to come up with their statistics.  You can read the details here: Scary, Unexpected "ACA Attrition Report" Neither Scary nor Unexpected (nice to see our enrollment expert still keeping track)  Spoiler alert - all they are seeing is what I would call a historically normal 2% a month attrition rate.  When this all first started we talked about churn - and here it is, but if anything in lower numbers than I might have expected.  Remember, there are a lot of good reasons for people to leave their Marketplace plan (new job with benefits, married someone with benefits, married someone on a different insurer's plan, etc.).  I guess the approach here was if you can't beat them, make stuff up...

ACA: Premiums/Costs

Speaking of not perfect, when early this year the administration extended the availability of transitional policies, no one was thinking about renewal rates.  Yet here we are, and while overall the rate hike news has been good (see last week's issue for a review of where things stand), some states are seeing troubling numbers.  Turns out the availability of the transitional policies are partly to blame - by letting them stay on the market, with their non-compliant benefits and resulting cheaper premiums, young healthy people are staying out of the compliant plans.  This causes issues with the rating pool:   Solving a 2014 Obamacare problem pushes premium hikes in 2015.

Meanwhile in CA, one of the states that did not take the administration up on the offer to continue transitional plans (remember, it was a state by state decision), the good news keeps on coming with a detailed look at rate increases: Kaiser cuts Obamacare rates 1.4% for 2015; Anthem hikes rates 4.6%

ACA: Marketplaces

Remember Mikey Dickerson?  He was one of the healthcare heros who desended on healthcare.gov last October to help fix it - well no good deed goes unpunished, so the White House Picks Engineer From Google to Fix Sites.  Mikey has been hired by the Feds full time to help bring the government into the 21st century.

Meanwhile, as we look towards the next open enrollment period, the Feds are trying to clean up the last one.   Notices went out this week to individuals who's paperwork was still not in order:  Over 300,000 Must Prove Eligibility or Lose Health Care.  Most of these people are legitimately getting subsidies, but have not yet filed the supplemental paperwork  required.  Locally, 1,200 Maine consumers could lose Obamacare coverage for failure to prove legal residency.  Advocates are working to get the word out, but if you know someone who's received a notice this week, make sure they understand that failure to act could put their insurance in jeopardy.

Heard enough from me yet about the issues we will face with the upcoming open-enrollment?  Sorry, they are not going away.  Here Vox takes a look at the situation: Here's why Obamacare enrollment will be super confusing next year, too .  The article links to great flowchart of reenrollment process, but if you want to cut to the chase, you can go there directly:  Renewals and Plan Management.

But it's not just re-enrollment that will be difficult, getting those currently uninsured into the system has its own set of new challenges in year 2.  Basically, we've picked the low hanging fruit so will need to work harder to get the next crop: Why Obamacare May Have Trouble Signing Up As Many Uninsured Next Year.

On the state marketplace front, MA has decided not to use healthcare.gov this year as they diligently work to fix their own site: Massachusetts pioneered Obamacare — and is still struggling to make it work. To help get there Mass Seeks $80M More From Feds For Health Website.

And in Oregon, the vendor who allegedly messed up their site has beaten that state to the punch as Oracle sues Oregon over botched Obamacare exchange.

ACA: Employers

On the employer front, two major stories out of the same survey.

First, more employers offering skinny plans than expected:  16% Of Large Employers Plan To Offer Low-Benefit 'Skinny' Plans Despite ACA: Survey.  We've talked about them before, but taking words from the article to review:  " It works like this: Employers can shield themselves from health law penalties by offering insurance that meets tests for affordability and value -- regardless of whether anybody signs up. At the same time, workers can avoid the ACA's individual penalty by enrolling in a company skinny plan, which qualifies as "minimal essential coverage" for individuals under the health law by the mere fact that it's employer-sponsored."

Meanwhile, more of the same as U.S. benefits enrollment season to bring more cost cutting: study.  To sum up, employers talk about adding  "consumerism" to employer plans - but that's just another way of saying they will push a greater share of the costs to employees.

And here is the source of all the information above: U.S. Employers Changing Health Benefit Plans to Control Rising Costs, Comply with ACA, National Business Group on Health Survey Finds (Primary Source).

Looking for more ramifications of the employer based coverage parts of our system?  Read this discussion with an employer advisor talking about narrow networks (not a bad thing if done right, but that's a big if) and reading between the lines, ways of shifting costs from the employer to the employee:  More Employers Limit Health Plan Networks But Seek To Preserve Quality, Says Adviser.

ACA: Court Cases

A lull in major court decisions this week, but that doesn't mean nothing's going on.  For an update, take a look at Jost's review: Implementing Health Reform: ACA-Related Litigation And Special Enrollment Periods (In addition to court cases he also provides updates on new special enrollment periods.)

ACA: Other

More thoughts this week on the ACA related paperwork that will be involved in filing your 2014 taxes - “That is so complicated,” CBPP’s Solomon said. “How does anyone understand that? The folks who are helping consumers are reeling. A consumer can’t be expected to understand this.” ( Consumers’ next Obamacare challenge: Tax forms).  Here is Jost's review of the logistics: Implementing Health Reform: Transferring Information Among The Exchanges, The IRS, And Taxpayers.

More talk about extending the PCP Medicaid reimbursement raise past the two years originally funded by the ACA: Democrats in Congress want to extend this temporary piece of Obamacare.

And continuing discussion of hospitals' attempts to figure out a way to pay their patients' premiums.  While it sounds good at first glance it can have ramifications for the risk pool:  Hospitals Seek To Help Consumers With Obamacare Premiums.

VA

As McDonald began to take control of the VA, he, talked about changes he will be making:  New V.A. Chief Promises to Mend Practices.  He also discussed the ramifications of some of the misbehavior by staff:  VA chief: Firings of workers a deliberate process.

Medicaid

Numbers from CMS showed that since the Oct 1 last year Medicaid has gained over 7 million enrollees: New Medicaid enrollments top 7 million under Obamacare.  But not all of them were in expansion states: Medicaid Rolls Are Growing Even in States That Rejected Federal Funds.  This is the result of the welcome mat effect (my preferred term over woodwork effect).

But think of how many more could be covered if every state expanded eligibility.  Here is a  look at the ridiculousness of not expanding:  A Deal Too Good to Turn Down, Unless It’s Medicaid.  And thanks to the Urban Institute, Another argument against the Medicaid expansion just got weaker (they show that the Feds have never reneged on a funding commitment to the program, contrary to what some critics site as their reason for not expanding).

Drugs

This week, Vox took a look at the science of weight loss and Why "metabolism boosters" are bullshit.

Meanwhile, there are lots of other drug scams out there - some being run by physicians and compound pharmacies.  They promote compounds that are expensive and unproven for no other motivation than profit:  "It may be the biggest thing in diaper rash treatment, a custom-made product to soothe a baby’s bottom at the eye-popping price of $1,600. ...  Does it work better than the common treatments? There is little evidence either way."    It's also worth noting that "Compounded drugs do not require F.D.A. approval."  (Pharmacies Turn Drugs Into Profits, Pitting Insurers vs. Compounders)

And of course our weekly Sovaldi update:  First a look at how In 20 years, we can make hepatitis C rare – if we can afford the cure.  Remember, Sovaldi is a case where there is no doubt as to the improved efficacy of the drug, the issue is cost.   In somewhat of a surprise move, UK Recommends Covering Sovaldi Hepatitis C Pill.  This is a clear endorsement of just how effective the treatment can be, but note that  ""The decision was likely helped by the lower price tag in the U.K. Gilead is selling its drug for about $56,000, according to a NICE spokesman."  That's about 35% cheaper than its price here in the US.

Costs

Were you looking for a new cost issue to worry about?  You're in luck because we've found one.  The idea behind urgent care centers is that they can provide a lower cost alternative to going to the ER.  But what if both options are run by the same system and instead of saving money, hospitlals try and use the urgent care center as an upsell opportunity: Increasing hospital revenues through urgent care referrals.

And speaking of hospitals, a study looked at CA hospital charges.  More data to something we already knew; there is incredible variation in charges for absolutely no reason.  For example   "One California hospital charged $10 for a blood cholesterol test, while another hospital that ran the same test charged $10,169 — over 1,000 times more."  (Wide Variation In Hospital Charges For Blood Tests Called ‘Irrational’).

  

System Transformation

We'll start this section with a story getting some appropriate local attention - a focus on vaccination rates.  We saw that More Maine families are skipping or delaying childhood vaccines.  In response, Maine legislators to seek stronger laws to get kids vaccinated.  (We've discussed this before, but for a review of the complete nonsense that is the anti-vaxers arguments, this is one of the best posts I've seen: Dear parents, you are being lied to)

Next a story that needs more attention - the amazing experiment that is Maryland and their hospital reimbursement system (yes, unlike most states, they really have a system): An Amazing Healthcare Revolution Is Happening In Maryland — And Almost No One's Talking About It.   Some excerpts:  "The key is to establish a model that works for all the patients, as Maryland has done. Some reforms in the Affordable Care Act, Sharfstein argued, don't go far enough.    Imagine, he mused, if Western Maryland were reimbursed on the basis of value for only 20% of the patients, while 80% remained on a fee-for-service model. It would never work. The diabetes clinic would never be set up, because they would be taking money out of their own pockets.    "What we're seeing at a place like this," Sharfstein said, "is true clinical transformation, which is the ultimate goal.""

More this week on the impact of leaded gasoline and the unintended benefits of eliminating it.  If you haven't "been exposed" to this research, the article has links to some of the other work on the topic: Childhood Lead Exposure Causes a Lot More Than Just a Rise in Violent Crime.

Imagine if a state could reduce teen birthrates dramatically - wouldn't it be worth replicating the experiment?  How Colorado’s teen birthrate dropped 40% in four years.

Some focus on hospital issues:

• Hospital Readmission Reduction Program Reignites Debate Over Risk Adjusting Quality Measures - a review of the need to take SES (socioeconomic status) into account
• Nonprofit hospitals at a tipping point from mounting challenges - biggest challenge is declining volume - which is good, we want to reduce hospitalizations.  This trend leads to more consolidations.  The problem arises when there is not enough oversight and these consolidated systems start charging monopolistic prices.

Some longer reads for your summer weekend:

• Vermont Is 'Single-Payer' Trailblazer - Pew Charitable Trust status update on their progress
• Maine State Innovation Model: Q3, 2014 - The quarterly newsletter from Maine's SIM project

And finally, the latest installment of Dr. House of Cards - you know you've been waiting: DR. HOUSE OF CARDS, EP. 3: OZ VS. UNDERWOOD.

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 22

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

This week we saw the first state level estimates of the reduction of the number of uninsured, thoughts on the next open-enrollment period (both re-enrollment and tax issues), Medicaid news, Medicare news, lots of cost news and as always, much more.  So here we go...

ACA: Polls/Opposition

The big data news this week was the release by Gallup of state level estimates of the change in the number of uninsured.  We've seen multiple studies make national estimates, but until now state level data has been hard to come by.  Since most of my readers are in Maine, we'll start there:   Affordable Care Act has lowered Maine’s uninsured rate, poll says.  Some guy quoted in the article said it was both a good and bad story here in Maine, he was right.  We did better than many other states that did not Expand Medicaid - thanks in no small part to the actions of the Maine Health Access Foundation and their grantees.  However the data serves to highlight how much more progress we could have made if we had expanded Medicaid. 

That story was played out across the country:  Arkansas, Kentucky Report Sharpest Drops in Uninsured Rate (Primary Source) both states, and in fact the ten states with the largest point drop in the percentage of uninsured,  did expand Medicaid.  You can see the state by state results graphically represented here: The very real impact of Obamacare opposition, in one map.  And finally, a reminder of What happens when a state tries to make Obamacare work; a case study comparing  KY to MS.

With this data adding to the already overwhelming evidence that the ACA is working, you would think the public would start to be more excepting...  but you would be wrong.  We have another survey showing us that Obamacare Bends the Reality Curve: in other words, your perspective informs your view of the facts, not the other way around (to be fair, this happens at both ends of the political spectrum)  Feeling better and worse about Obamacare (Primary Source).

Although while public perceptions have not appreciable changed, it seems the magnitude of their feeling may have as Obamacare loses some of its campaign punch for Republicans.  The Republicans never did introduce the "replace" part of their repeal and replace strategy and it seems the issue is losing traction on the campaign trail.

ACA: Premiums/Costs

I'm using this section to focus in on premiums and rate review.  But there are also impacts of the ACA on the overall health system cost picture so don't forget about the general cost section below.

A large consulting firm took a look across the country at what the renewal rates are looking like, and no surprise, How Much Is Obamacare Raising Your Insurance Rate? Depends on Which State You Live In.   (You can see the original study here: A preliminary look at 2015 individual market rate filings (Primary Source).)

Before looking at some state specific results, some pieces looking at broader issues.  In this detailed story from CT a look at public rate hearing and the impact they had (or didn't have) on the rate review process: Do public hearings influence what health insurance costs?.  And some thoughts on the overall significance of the rate requests: Decoding 2015 Health Insurance Rate Increase Requests.  And finally, while the ACA allowed a smoker surcharge of up to 50% of the premium, that's not what they paying: Smokers Paying Less For Some Health Plans Than Expected.

Now a look at some state specific results:

• More debate in Florida over both the cause of the 13.2% rate increase announced last week: Advocates Say Florida Consumers To Pay For State Lawmakers’ Decision (lawmakers had decided last year to suspend rate review because they did not want to "participate in Obamacare") and over what the rate increase really is: White House: Rates in Florida will decline for Affordable Care Act exchange plans " The White House analysis showed the monthly premium for the second-lowest silver plan in all Florida counties will drop by an average of 4 percent."
• In Tennessee a man bites dog story as A Tennessee Insurer Uses Its Monopoly To Deliver Bargain Premiums - yes you read that right, an insurer with near monopoly power is using that power for good instead of evil (so far at least).
• And finally, Oregon releases 2015 health insurance plan rates where we see a tightening of the market with last year's low priced entries raising their rates and the high priced entries lowering their rates.

ACA: Marketplaces

November and the next open-enrollment period is getting closer every day...  A Health Affairs post looks forward and says An Ounce Of Prevention For The ACA’s Second Open Enrollment.  Meanwhile, more articles highlighting the problems inherent with the auto renewal process set to be used by the marketplace: The Latest Obamacare "Glitch" Isn't a Glitch At All—and It's Democrats' Fault and If You Like Your Obamacare Plan, It'll Cost You. We've discussed this before, but to me the warning can't be repeated enough:  " "I would expect that probably the majority of 2014 enrollees are going to be impacted pretty substantially," said Milliman analyst Paul Houchens."  Individuals who auto renew without updating their financial information and looking at plan choices open themselves up to unpleasant surprises. 

Also looking forward, a story telling us that Exchange Assisters Want More Training To Help Consumers — Even After They Enroll.

Looking back, while we've heard that millions of subsidy calculations may have been wrong, " A government investigation released Tuesday found that the agency was 100 percent accurate in calculating the maximum monthly subsidy for all requests in the first two weeks of October. "  (O-Care subsidy calculations accurate last October, audit finds).

ACA: Court Cases

No court ruling this week (at least as of Friday morning) but that doesn't mean there isn't anything to talk about on the topic.  Drew Altman latest takes A Closer Look at the Courts’ Impact on Health Policy.

And a survey shows that People don’t get the new Obamacare lawsuits, but they think all exchanges should provide subsidies.

And a few nuggets on the more impactful cases:

• 5 media mistakes in the Halbig debate
• GOP senator to appeal ObamaCare lawsuit -the congressional staff one
• Hobby Lobby Ruling May Have Poked A Hole in The 'Corporate Veil' - the law of unintended consequences.  Did the Hobby Lobby decision open up the owners of those closely held businesses to liability?  If their religious beliefs can pass one way, does responsibility pass the other way?

ACA: Other

From our friends at the Center for Budget and Policy Priorities, here are The Tax Rules That Health Care Assisters Need to Know - and here is the link to the guide:  The Health Care Assister’s Guide to Tax Rules (Primary Source).

Staying on the topic of taxes for a bit, here is a good overview of The Relationship Between Taxes and Health Care: 5 Things You Need to Know.

And here is a CMS presentation reviewing information, including the new tax forms: The Premium Tax Credit.  Please note that 1095a is sent out by the marketplace and will be sent in Jan of 2015 (for the 2014 tax year).  1095b and 1095c will come from insurers and employers - it is not mandatory that they send them out until Jan of 2016 but are "encouraged" to do so in Jan of 2015 (for the 2014 tax year).  So far I've seen no indication as to how many will do so but if I had to guess I would say not many.  Regardless of the 1095s, everyone receiving tax credits will need to complete 8962 when they file their 2014 tax returns.

Taxes are one area that is complicated, but even more fundamental is the use of insurance:   Newly Insured, Many Now Face Learning Curve.

We've written about the situation in Florida where several insurers were using their formularies to discriminate against AIDS patients and others, a look this week at some indications the problem may be more widespread: AIDS patients fear discrimination in ACA exchange.

On the positive side, the firm behind one of the most used credit scores announced that "the latest version of its score would no longer weigh medical debts — which account for about half of all unpaid collections on consumers’ credit reports — as heavily as it did in previous iterations" (Credit Scores Could Rise With FICO’s New Model ).  When and if the new methodology is adopted by FICO's clients it could result in the improvement of many individual's scores.

Some insight what the 19-34 year olds are thinking about health insurance: Findings from the Deloitte 2014 Survey of Young Adults and Health Insurance  (sorry, there's not a single headline result for me to share but for those working with these populations it is a deep look into their attitudes).

VA

Thanks in no small part to our own Congressman Mike Michaud (standing behind the president in the photo), Obama Signs Bill Aimed at Fixing V.A. Shortfalls. 

Medicaid

A new report from RWJ and the Urban Institute showing (again) how much states are losing by not expanding Medicaid: MAP: Your State Lost Billions by Refusing to Expand Medicaid and What Is the Result of States Not Expanding Medicaid? (Primary Source).

Some states who did expand required premiums from some participants, turns out that was effective in keeping people off the program since premiums for Medicaid and CHIP discourage participation, no matter how small they are:  You Qualify for Medicaid: Don't Sign Up.

And in the state that started the "private option"  and a look at how, one year into a three year waiver, they are trying to change their plan.  Of note (and concern) is the attempt to limit or eliminate the transportation benefit from Medicaid: How Arkansas explains the politics of Obamacare.

Medicare

A First Look At Medicare Quality Incentive Program Finds Little Benefit - what's important to remember is that there is a reason for piloting a program, figuring out if it will work or not.  Often we forget that a negative result can be just as helpful as a positive one.

On a more global front: Medicare Reduces Payments for 2015 Hospital Admissions.

This next item fits in either this section or the following one devoted to drugs.  The Obscure Drug With a Growing Medicare Tab - there is so much wrong with this situation.  Medicare does not have the authority to limit reimbursement for the drug, even though "...in the absence of such scientific studies, some private health insurance companies, as well as Tricare, the military’s health care program, have curtailed or eliminated spending on Acthar."  Plus, "Several of the top prescribers of Acthar have financial ties to the drug’s maker, Questcor."  And it should come as no surprise that Top Medicare Prescribers for Acthar Have Links to Its Maker.

Drugs

One physician's Adventures in ‘Prior Authorization’.  You won't be shocked to hear that I have lots to say about this.  My reaction can be summed up as don't throw the baby out with the bathwater.  The author clearly had an indisputable case and the process he had to follow was byzantine at best.  That said, many providers don't consider the cost of the prescriptions they writ.  So while we are stuck with the current system, there is still a need for prior authorization.   Seems like I keep coming back to this point week after week, but I won't let that stop me:  Don't blame the policy for poor implementation (filed under don't throw the baby out with the bathwater).  This author has a legitimate problem with the process he had to go through, but that doesn't mean the idea of making sure providers think about the cost of their prescriptions is a bad one.

And now for our weekly Sovaldi installment.  Here is a look at its introduction compared to other drugs - the issue with Sovaldi is that the market is in the "mass market" range but the price is in the "specialty" range - thus its disproportionate impact on medical budgets (and an explanation for the amount of concern it's causing (Why the Price of Sovaldi Is a Shock to the System).  Also a look at Why the Hepatitis Cure Sovaldi Is a Budgetary Disaster for Prisons - reminding us of some of the unique problems inherent in our prison systems and attempting to provide health care to prisoners (not exactly a popular budget item).

Costs

We've talked before about the historic slowdown in health spending.  This week a new study to add to the conversation, this one pointing to the recession as a larger factor: Studies: Thank the recession for the health spending slowdown.  That said their results explains 2008-2011, not what's happened since then.  (Health Spending Slowdown Is Mostly Due To Economic Factors, Not Structural Change In The Health Care Sector (Primary Source))

When it comes to costs, Hospitals And Health Plans See The Future Very Differently.  There is a good reason for that, hospitals tend to look at their total budget while health plans look at per capita spending.  So as second quarter investment results come in from the two groups, you get a very different view of the environment. 

An entertaining look at heath care economics (yes, it can be entertaining): Employer-Based Health Insurance 'Cheaper' Than Government-Sponsored Insurance? Say What?  "Every so often in punditry land there appears a column so egregiously flawed that it makes a perfect platform for a homework assignment in undergraduate health-economics courses.  ...  So we must thank Sally Pipes for contributing to pedagogy a veritable jewel along these lines in her July 28 Forbes article, entitled “Employer Health Insurance: A Bargain Compared to Government-Sponsored Coverage.”"

A look at one program where House Calls Keep People Out Of Nursing Homes And Save Money. 

Some focus on transparency this week.  First a look at a study that showed When health care prices stop being hidden, and start getting real.  Also, one health system asks itself the question Exactly How Much DOES That Appendectomy Cost?   Often the system itself doesn't know the answer (note that I've just switched from price to cost, both areas where transparency is important).-The are marshaling their data to produce a comprehensive costing too. 

Taking comparison shopping in health care to a whole new level:  Like Priceline for patients: Doctors compete for business via online bids for surgery.  But if that's not for you, here is The secret to negotiating a lower medical bill.

More evidence that there truly is no relationship in health care between price and quality, this time from the team that used to think there was one: "Doyle 2 found "no association between total one-year spending and patient outcomes.”"  (Expensive Hospitals Aren't Any Better).

And always worth remembering that while we talk a lot about system reform (as we should) the single biggest reason we spend so much more in this country than anywhere else is we allow the prices of health care services to go unchecked. Look at these charts and think of what could be done with the money saved. And remember, our quality is no better (and often worse) than other countries:  Our health spending problem is all about prices.

System Transformation

In this section we talk about system transformation.  This week let's look back and Watch America transform from making things to taking care of people.  The change shown is not inherently good or bad - but it's important to keep in mind as we work to stir things up.  I can say (until I'm blue in the face) that health care is not a jobs program, but for many it has become just that.  As we work to reduce costs there will be disruptions that need to be taken into account.

And speaking of disruptions, lots on the workforce front this week:

• The Drawn-Out Medical Degree - Do we take too long to train Doctors?
• Not enough primary-care doctors? Try Missouri's prescription. - They are putting med school grads to work even before their residencies.
• California Asks: Should Doctors Face Drug Tests? - Should they continue to be the only profession that we are not testing?  (Are they any different than pilots who are tested?)
• The Physician Assistant Will See You - We can use other practitioners for certain roles.
• In Ambitious Bid, Walmart Seeks Foothold in Primary Care Services - We can try providing care in unconventional settings.  Put aside any feelings you may have about Walmart, this initiative is worth watching.  Of course we need to make sure any care provided is well integrated into the patient's overall care plan.

How do we integrate care from different providers?  Of course one way is through electronic health records and data exchanges to share that information.  Here in Maine we have HealthInfoNet.  In CA Insurance giants creating massive database of patient records  to facilitate the process.  

Note the difference between a data exchange and a health record - the exchange (the item above) makes sure that information on any one record contains information from different providers.  That's complicated by the fact that there are many different systems out there.  This week RWJ released their annual review focusing on the implementation of electronic health records:  Health Information Technology in the United States Progress and Challenges Ahead, 2014 (Primary Source).  You can read a brief account of the report here: Electronic health records were supposed to be everywhere this year. They’re not — but it’s okay. 

Electronic records hold the promise of helping improve care and lower costs, but they have their dangers as we hear in The disturbing confessions of a medical scribe it seems they can make fraud easier- only a click away...

Several not so good transformation stories this week:

• Feds stop public disclosure of many serious hospital errors
• Rising rates of hospice discharge in U.S. raise questions about quality of care (third in series, links to earlier articles are embedded in this one)
• Study: Emergency room closures can be deadly for area's residents - caution, proceed with caution.  I include this in the interest of completeness but it seems like the study was done with a very broad brush and does not at what is going on or the fact that there are different types of closures or that facilities can be replaced with different types of services
• U.S. insurer to stop coverage of gynecological procedure - good! "the spinning blade of the morcellators could spread deadly cancer and worsen patient outcomes, the FDA had warned"

A reminder that Vitamins are not magic. We need good science and better sense. (Or as Sheldon would put it, vitamins are sometimes a way to make expensive urine.

Thoughts on the importance of communication (and listening).  Starting with The first-year medical student and the 114-year-old patient.  Followed by A physician responds to OpenNotes critics (why there is no downside to full transparency with your patients).  And finally the presentation and replay information from a great webinar held this week by our friends at Quality Counts.  The topic is Shared Decision Making, the speaker is excellent and it's an interesting (and important) topic.

We'll end this week with one man's guess as to how all this change plays out - his vision sounds good to me, now we just have to get there:   Health care at half the cost: What will that actually look like? -

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!

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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"