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!
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"
