A look back at the week's health policy news with a
focus on ACA implementation
November will make change the lives of millions of people in
this country. The results of the election on November 4 will decide if more states
(including Maine) will participate in the Medicaid expansion. Then on November
15th open enrollment begins giving many access to quality affordable health
care that they never had access to before.
This week we'll look at what's going on with the ACA
including from new polls, open enrollment developments and ways to improve the
law we'd be talking about if we lived in a world where so much energy didn't
have to be spent defending the laws existence. Also data, dangerous drugs, end
of life care and inevitably Ebola. Here we go.
ACA: Polls/Opposition
We'll start off with some good news. Although "health
insurance" literacy is a problem for many, a recent poll found that Voters
Know Insurance Basics Heading Into Open Enrollment. Among the survey's
findings was that 77% of respondents could define a deductible (although the
other 23% still need help).
On the other hand, this month's Kaiser
Health Tracking Poll found that Only
11 Percent of Uninsured Know About Obamacare’s Next Open Enrollment. With only
three weeks before it starts, this result highlights the amount of outreach
that will be needed.
On the political front, lots of drama as Gov.
John Kasich’s view on Medicaid fuels two-day spat with AP. Basically, he
said that the ACA wasn't going anywhere because it was helping people - he then
rapidly walked back his comments (Ohio's
GOP governor says Obamacare is helping people, then rapidly retreats). Nonetheless,
in some respects This
Republican Just Made the Best Obamacare Pitch of Any Politician. The key sentence:
"The opposition to it was really either political or ideological. I don't
think that holds water against real flesh and blood, and real improvements in
people's lives."
ACA: Marketplaces
Secretary Burwell spoke to the American Academy of Family
Physicians this week and told them: “We're going to need your help and your
support just as much as we did last year, if not more” (HHS
chief rallies docs to boost ObamaCare enrollment).
We learned this week that Healthcare.gov's
Ez Form Not For Legal Immigrants. Specifically, they will not be able to
use the new 16 screen form and instead must use the old 76 screen one because
they will automatically be classified as "complex cases". This issue
joins the long list of things that could be addressed if more people were concerned
about making the law work well instead of just criticizing it and trying to get
rid of it (another example of this leads of the cost section below).
The Commonwealth Fund shared its thoughts on reenrollment
with a useful overview: Keeping
Covered: The Affordable Care Act’s First Reenrollment Period for Marketplace
Plans.
Two reports were released drawing lessons from history to
help with open enrollment. The first: Open
Enrollment: Insights from Medicare for Health Insurance Marketplaces presents
a cautionary note that while reviewing one's current marketplace plan during
open enrollment is the smart thing to do, Medicare Part D experience says it's
an uphill climb to get people to do so. The second: Report
from the First Year of Navigator Technical Assistance Project: Lessons Learned
and Recommendations for the Next Year of Enrollment is a new report from
Georgetown and RWJ drawing lessons from last year's experience.
ACA: Employers
The Wall Street Journal takes a look at how some businesses
are reacting to the law: Restaurant
Owners Look for Creative Ways to Escape Health-Law Penalties (no
subscription required for this article, don't ask me why, when the Journal
enforces its pay-wall remains one of life's great mysteries). Unfortunately,
instead of accepting the law as a cost of doing business some look for creative
ways around it.
Also this week, Sam’s
Club to launch a private health insurance exchange. Private exchanges have
been around (and growing) for large firms, but this is specifically geared to
small employers. Remember, private exchange participants are not eligible for
any subsidies (for either individuals or the small business). What they do
offer is a way for employers to switch from a defined benefit health plan to a
defined contribution plan - they just designate a sum of money for each
employee - what they buy with it is up to them (and there are no guarantees
there will be something affordable for that sum of money).
On the public exchange front, Obamacare’s
small-business exchanges to see major changes in the coming months. This
article looks at some state specific small business marketplaces as well as the
federal one.
ACA: Court Cases
The Rand Corporation produced a rather sensationalist report
this week reacting to the Halbig case: Assessing
Alternative Modifications to the Affordable Care Act Impact on Individual
Market Premiums and Insurance Coverage (Primary Source). The report evaluates
what would happen to the Marketplace if the subsidies went away. However it
assumes they go away in every state and ignores the real possibility that even
if the suit was ultimately successful before the Supreme Court, there are ways
to still use the federal IT platform and call it a state exchange
(marketplace). Here is a review of the report from the Washington Post: How
the Supreme Court could still wreak havoc on Obamacare
Also from our friends at the Washington Post: The
ongoing Hobby Lobby battle: Who else can get an exemption? The easiest way
to describe where things stand with respect to the Hobby Lobby battle is with a
one word summary: "confused".
ACA: Other
More guidance out this week from CMS with respect to the
Basic Health Program. This is an option open to states as an alternative way to
cover those earning between 133% and 200% of FPL. You can read the CNS fact
sheet here: Fact
sheets: Basic Health Program Funding Methodology Proposed Notice. Maine's
Health Exchange Advisory committee discussed the concept and heard a
presentation on the plan and alternatives. The September 22 Meeting
Materials include the presentation (towards
the end).
Other technical guidance has been released recently, for a
review we turn to Tim Jost's Health Affairs Blog: Implementing
Health Reform: The Qualified Health Plan Federal Exchange Participation
Agreement And More (fairly technical but of interest to some of us).
RWJ released a report: Essential
Health Benefits: 50-State Variations on a Theme. This will be extremely
important information in 2015. Remember, originally, there was going to be one
national definition of essential health benefits. Instead, each state has their
own definition, but that is only for the first two years (2014 and 2015) of
implementation - anytime now we'll hear what the plan is for 2016. Regardless
of what the plan is, expect fireworks after the announcement.
"With an estimated 25 million new people becoming
insured over the next few years, a coalition of family physicians has a message
for the country: Don't forget about us. ... The timing is right for the group, which
on Thursday announced a five-year, $20 million campaign aimed at promoting the
importance of primary care. The flood of newly insured patients presents a big
opportunity for primary care doctors, when you consider this: just one-third of
uninsured adults said they have a regular doctor, about half the rate of the
insured population, according to a 2013 Kaiser Family Foundation survey."
(Primary
care doctors to patients: Don’t forget about us).
Costs
On top of that list of issues to address to improve the law
is the issue of affordability. From the "family glitch" to high
deductibles, we know there are people who are not able to get the full benefit
of health coverage given current circumstances. This was highlighted in the NY
Times piece: Unable
to Meet the Deductible or the Doctor. I will note that the piece looks at cases
that fall into two broad categories. First there are those who may have been
better served making a different choice on the marketplace such as a silver
plan where they may have been eligible for cost sharing subsidies or even a
more expensive gold plan. The focus on premium as opposed to overall cost
during the year can lead to these types of problems. Second is the group that
did everything right but nonetheless end up with greater costs than they can
afford. Unfortunately in our system focused on health coverage instead of
health care, these circumstances will inevitable arise.
This week HHS Secretary
announces $840 million initiative to improve patient care and lower costs “The
administration is partnering with clinicians to find better ways to deliver
care, pay providers and distribute information to improve the quality of care
we receive and spend our nation’s dollars more wisely,” said Secretary Burwell.
“We all have a stake in achieving these goals and delivering for patients,
providers and taxpayers alike.” And more
info here: Transforming
Clinical Practices Initiative
Also on the cost front, reference pricing is back in the
news. A review from Kaiser: More
Plans Setting Spending Limits For Some Medical Services and a study
published on the potential extent of savings: The
incredible cost savings that are possible when patients can actually shop
around. I do take issue with the headline (as I often do). While the
savings are real, they won't fix the system (we've discussed other studies
previously that looked at total savings possible). There is also this caution
about the strategy: "Health care economist Uwe Reinhardt, writing in a
separate JAMA editorial, says the early results seem to support expectations
that transparency in health care can lower spending. But it only works, he
cautions, if there's enough provider competition. "It is a point that is
sometimes overlooked but is an essential ingredient for patients to benefit
from knowing the price and quality of the health care services they
purchase," he writes."
And speaking of competition (or lack thereof due to consolidation):
Study:
Medical costs up to 20% higher with hospital-owned physician groups
"" Total spending per patient was 10.3% higher for hospital-owned
physician offices compared with
doctor-owned organizations, according to the study. ... Costs were even
higher when large health systems running multiple hospitals owned medical
groups. Their per-patient spending was 19.8% higher compared with independent
physician groups."
Much has been made of the Medicare cost slowdown. Upon
further analysis it appears You
may want to thank George W. Bush — not Obamacare — for the remarkable Medicare
cost slowdown. It seems that Medicare Part D is a big part of what's
happening: " In a recent analysis of the Part D slowdown, the CBO
concluded that it can be almost entirely explained "by broader national
trends in per-capita drug spending that occurred as a result of the
pharmaceutical technological slowdown" -- as well as lower-than-expected
enrollment in the prescription drug program. ... "The decrease in Medicare
spending growth has already been a remarkable shift, and prolonging the
slowdown in Parts A and B would be a tremendously important contribution,"
the pair write. "Unfortunately, though, the outsized role that Part D has
played in the Medicare slowdown is bad budget news because it may prove fleeting.""
Medicaid
There may have been news out of Utah this week but we're not
sure. Gov.
Herbert: Deal is done with Obama administration on Medicaid alternative. There
were no details released: "The governor expects to share details of his
plan with legislators in mid-November, and there will be a 30-day comment
period for the public as well." Additionally, we're not even sure if the
deal is final: "David Patton, executive director of the Utah Department of
Health, however, told lawmakers Thursday that negotiations continue on a few
details, specifically a table of co-payments that low-income Utahans would make
for medical services under Healthy Utah."
Drugs
Apparently, CVS wasn't satisfied to stop selling tobacco
products in their stores, they want all pharmacies to do so. To achieve that, CVS
has a plan to strong-arm other pharmacies out of selling cigarettes. They are
planning to impose an additional copay through its Caremark pharmacy benefits
manager business for drugs purchased in pharmacies that sell tobacco products. Expect
to hear more about this. While the goal may be admirable it has the potential
to end up costing consumers more money due to factors they have no control over.
(Plus it sounds a little like using their PBM power to force customers to their
retail pharmacies...) Stay tuned!
Meanwhile, here are three stories where we know for sure
consumers are being harmed:
- Dangerous Dietary Supplements Return to Store Shelves "The study found that two-thirds of the 27 supplements analyzed contained at least one unlisted anabolic steroid, prescription drug or banned substance. A majority contained the same drug or illicit ingredient that led to them being recalled by the agency."
- On an Antibiotic? You May Be Getting Only a False Sense of Security
- Warning: This Parkinson's drug can make you addicted to gambling, sex, or food
System Transformation
How do we know if a treatment is appropriate? Is there some number that could be told to
patients (and providers) to help them decide if a treatment is appropriate?
"That number exists, and it’s called the number needed to treat. Developed
by a trio of epidemiologists back in the ’80s, the NNT describes how many
people would need to take a drug for one person to benefit. (The NNT for
antibiotics in a case of acute bronchitis is effectively infinity, because the
medicine is no better at curing the illness than a placebo.)" A potentially crucial part of the movement
towards evidence based case, you can read more about NNT here: This Man’s Simple
System Could Transform American Medicine.
Atul Gaawande's new book on end of life care is now out. First
a book review from Janet Maslin from the NY Times: A
Prescription for Life’s Final Stretch (remember when Janet Maslin was their
film critic? I miss her film reviews). And from our friend Ezra Klein, here are
9
lessons Atul Gawande taught me about dying. Meanwhile, on the same topic
here in Maine, the most recent entry in the continuing series: Someone
to watch over THE JOURNEY’S END.
Some focus this week on organ transplants and the organ shortage
that exists: An
organ shortage kills 30 Americans every day. Is it time to pay donors? and America's
Organ Transplant Law Is Criminally Unfair to Donors.
One physician take a fresh look at EHRs and how they are
doing: The
EHR report card 2014: Has it gotten better? "While the software is not
evolving as quickly as I would like, the ways that I interact with it are
changing more rapidly. I’m always finding new (usually better and faster) ways
of doing things." He reaffirms that
yes it has been slow going, but there is value to be had (unlike some who are
ready to get rid of them all).
On the quality front, people in Maine had reason to be proud
this week as the Washington Post said: Best
state in America: Maine, for its hospitals. It's a nice headline, and it's
true that a greater percentage of Maine hospitals got an A rating from Leapfrog
than any other state, but that doesn't mean we're done. We have a lot to be
proud of here in Maine but there is still a long way to go.
If you need a reminder that health care itself needs
improving, here you are: Mistakes
in Treating Childhood Fractures
"A pediatric orthopedic team at the University of Maryland School of
Medicine examined the splinting technique used in 275 young patients, who
averaged 8 years old. In 93 percent of the cases, the injury had been wrapped
improperly, according to a study presented this month at the American Academy
of Pediatrics conference in San Diego."
Ebola
And finally, inevitably, we'll talk a little about Ebola. Today
(Friday 10/24) the number of cases in this country reams constant - but that represents a swap of a new case in
New York for a cured case (one of the Dallas nurses).
Ebola is a huge problem, but not here in the US. Here's a
reminder of what real tragedy looks like: Video:
Inside the Ebola Ward
Most of the coverage remains sensational, but so far policy
remains restrained in that the Feds have not succumbed to pressure to institute
a travel ban. Why not you ask? The
evidence on travel bans for diseases like Ebola is clear: they don't work. Instead
we have The
CDC's New Ebola Plan Is Better Than a Travel Ban. And while some argue Why
new post-entry screening in the US is unlikely to catch Ebola, even this
author ends up saying "it should avoid a travel ban, which is a good
thing".
And while the Maine CDC creates its own resource page Ebola:
Information for the Public the Bangor Daily News appropriately says: Worried
about Ebola? Grab a bar of soap.
I took a long time deciding if I was going to include the
next link or not - it's a song parody about Ebola - but I finally decided to
share it along with the introduction provided by its creator:
"Ebola is NOT funny... ...but the absurd US media
hysteria about the virus is ripe for some ZDogg ridicule! So ZDoggMD Industries has once again teamed
up with musical legend Devin Moore from the band Rabbit! to pull the plug on
Ebola...or at least perform Ebola unplugged. And as you watch, please send your thoughts
(and hopefully some aid) to those suffering from this massive humanitarian
tragedy in Africa, and our affected healthcare workers here at home."
Interested in helping?
Consider contributing to
Doctors without Borders
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"
