Friday, December 19, 2014

That Was The Week That Was - Issue 41

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

Expecting a holiday lull?  Sorry but health policy waits for no one. This week in addition to a new Surgeon General (finally!) we have poll results, enrollment numbers and lots of Medicaid news. Also CMS was busy with announcements (see the special section below) and we will talk about a dramatic announcement in a socialist state, as well as what’s going on in Cuba (fooled you). The socialist state I refer to (out of deference to Bernie Sanders) is Vermont, where the Governor announced this week he was giving up the pursuit of a single payer health system.

Please note, there will be no issue next week but I will return with Issue 42 on Friday January 2. I hope everyone enjoys the holidays and has a happy and safe New Year.

Since this is the last issue of the year, we’ll start off with a brief look back at 2014:

Remember Ebola?  It’s still a severe problem in West Africa, but in spite of all the fear mongering many in the US seem to have forgotten all about it. This week Politifact called the false claims about Ebola the Lie of the Year: 2014 Lie of the Year: Exaggerations about Ebola. But it wasn’t alone the only lie, here Vox lays out The 8 most bogus health claims of 2014. And finally, as a tribute to the geek in all of us, the Top Ten Healthcare Charts For 2014. Now on to this week’s news.

ACA: Polls/Opposition
In addition to their Health Policy Tracking Poll (see below), Kaiser looks at what news events people are paying attention to (Kaiser Health Policy News Index: December 2014)  Two interesting piece from this month’s results: First over half the population does not know the marketplace is working better than last year - “When asked how the website’s functionality compares with last year, nearly half of the public (48 percent) say there have been fewer problems, 31 percent say the number of problems is about the same, and only 9 percent say there are more.” And second, concerning the subsidy case that will be heard by SCOTUS in the spring - “A large majority (84 percent) of the public say they have heard “only a little” (29 percent) or “nothing at all” (55 percent) about the case before the Supreme Court.”

This month’s health tracking poll didn't have any real surprises with respect to the raw numbers, but the focus on how changeable people’s opinions are is fascinating (Kaiser Health Policy Tracking Poll: December 2014) “Kaiser found that support (for the employer mandate) and opposition (to the individual mandate) are a lot less firm than one might think” (Obamacare Isn't As Divisive As You Thought) and Public Easily Swayed On Attitudes About Health Law, Poll Finds “The poll also found that a year into full implementation, most Americans, and most of those without insurance, remain unaware about many of the health law’s major features.”

More confirmation of the success of the law in reducing the number of uninsured, as Time magazine reports Number of Uninsured Americans Near Historic Low “The data released Thursday from the National Center for Health Statistics’ National Health Interview Survey found that 11.3 percent of Americans were without coverage in the second quarter of 2014, down from 13.1 percent in the first quarter and 14.4 percent throughout 2013. An analysis by the White House Council of Economic Advisers finds the drop in the uninsured to be the largest in four decades, amounting to roughly 9.7 million Americans getting insurance, consistent with other Affordable Care Act estimates.”

While those newly covered are much better off now, they are not the only ones benefitting. The LA Times takes a look and reports the health care industry isn’t doing too badly either: Uninsured rates fell under Obamacare, but who's reaping the benefit?

Here is an interesting perspective on what Republicans would do if the SCOTUS disallows subsidies in Federal Marketplace states. Remember, states that had set up their own marketplaces would continue as before, potentially setting up a two tier system in the country – would Republican’s really allow that to continue? If the Supreme Court Breaks Obamacare, Will Republicans Fix It?

ACA: Enrollment/Marketplaces
This past week saw the formal deadline for enrolling in coverage effective January 1. Lots of effort went into the last minute rush. Here in Maine: Mainers rush to enroll in health exchange The Federal Health Exchange Sees Enrollment Flurry and in spite of that, HealthCare.gov holds up amid record traffic on deadline day.

The deadline was Monday – unfortunately, the weekly enrollment reports (released each week on Tuesday) run Saturday through Friday, so the numbers we have so far aren’t complete. In spite of that we saw Obamacare’s Best Week Yet Brings 1 Million New Sign-Ups. You can see the HHS release here: Open Enrollment Week 4: December 6 – December 12, 2014. In addition to the million on the Federal Marketplace, we saw More than 700,000 enroll through state insurance exchanges in first month. Putting that all together, a research firm revised its projections: Avalere Analysis - Exchange Enrollment Outlook: 10.5 Million to Sign Up by End of 2015.

Although things went well with this initial deadline, there were some who couldn’t get through to the call center. They will be given extra time to enroll and still have their coverage begin January 1: Call center wait won't stop Jan. 1 insurance coverage. In some states (not Maine) insurers also made special allowances for the deadline: Insurers have pushed back a key Obamacare deadline in 37 states. There were some other circumstances where people will be given extra time, as outlined by Tim Jost: Implementing Health Reform: Enrollment And Reenrollment For 2015 “The FFM has, however, established special enrollment periods for a small group of qualified individuals who should have been passively reenrolled with coverage effective January 1, 2015, but for some reason were not.”

Before continuing, let’s take a minute to review the calendar. The 12/15 deadline was to get coverage beginning January 1. That applies to those who are seeking coverage for the first time and to those who are renewing coverage. Both groups still have two months to select a plan (open enrollment ends 2/15), it’s just that for those who are going to be auto-reenrolled (about 80% of those with marketplace coverage from last year) it will be more complicated to switch plans since their existing coverage will already have been renewed.

With that in mind, the expectation had been that if people were going to alter their reenrollment choice, many will have done so by the 12/15 deadline. The numbers above show that while some of those who had existing coverage have done so, the vast majority have not. Two pieces look at that situation: Obamacare Is Only Human (alternative title, Obamacare Has A Problem: Human Nature) and this one that looks at the impact of inertial on pricing decisions of carriers: Most Obamacare enrollees are ignoring tonight’s deadline, and it will cost them “The ACA exchanges were constructed with that idea that transparent competition would help act as a check on unreasonably large premium hikes. But that could also depend on people wanting to shop around for a better deal on coverage.”

ACA: Employers
After two years of delay, part of the employer mandate takes effect on January 1. Employers with 100 or more employees will need to offer coverage or face penalties – it seems like the delay may have served to ease the impact with the economy (somewhat) improving: ACA employer mandate: Not as bitter in better economy.

For small businesses who are not required to offer coverage, things are still challenging: Round 2 for the ACA Health insurance options still a challenge for small businesses. Small employers face a tough decision on if they should offer coverage or not – remember, some employees are actually better off if their employer doesn’t offer coverage because of the availability of subsidies on the individual marketplace. So it was inevitable that Small Businesses Drop Coverage As Health Law Offers Alternatives. Although, as this story highlights, some small businesses are seeing a benefit: Taking the pulse of SHOP exchanges

ACA: Other
In news that saddened single payer advocates everywhere, After years of effort, Vermont's governor reportedly gives up on single-payer health care. “It became clear that risk of economic shock is too high at this time to offer a plan that I can responsibly support for passage.” Governor Peter Shumlin (Governor Abandons Single-Payer Health Care Plan). While this is unfortunate for those who think single payer has merit, it is important to realize that it isn't working in Vermont because people don't accept the tradeoff of higher taxes vs. no insurance premiums, not because the theory is bad. My take is that optics, not finance is what doomed those efforts.

On a positive note, the Press Herald took a look at one of the predicted benefits of the ACA, that the presence of affordable individual insurance would allow individuals to give up their “day job” and pursue new opportunities: Affordable Care Act swelling ranks of self-employed, report says.

Costs
How does your doctor or hospital decide how much to charge for a test?  “Testing has become to the United States’ medical system what liquor is to the hospitality industry: a profit center with large and often arbitrary markups.” (The Odd Math of Medical Tests: One Scan, Two Prices, Both High) – Sounds like yet another compelling case for price negotiations/controls on the Federal level (like just about every other country does).  

Need more reasons?  How about “nonprofit” hospitals forgetting what it means to be a “nonprofit” or charitable institution: From the E.R. to the Courtroom: How Nonprofit Hospitals Are Seizing Patients’ Wages. In the case discussed, if the charges had been incurred just a few months later, they would have been waived. But instead the hospital is taking full advantage of every legal recourse, seriously harming the family involved.

That is one case at one hospital (although we can imagine it is not an isolated incident). What is going on across the country?  The NY Times asked, here’s a look at How the High Cost of Medical Care Is Affecting Americans.

These examples are important to keep in mind when (if?) we start to discuss changes to the ACA. Some (me!) would say the law needs to do more to help some of these people experiencing affordability issues while others (the bad guys) want to get more “blood from a stone” and increase low-income individuals share of expenses (can you say Copper Plan). Stay tuned!
For those who want to argue that the free market can take care of all this, here are 10 reasons why healthcare isn't a free market Spoiler alert!  My favorite is number one: “Nobody in the middle of a heart attack shouts, “Let's go shopping!””

With all that in mind, there is still a cost (and price) crisis in health care – and we need to be doing things differently if we want to fix it. Unfortunately, in the current environment it’s hard to have open discussion on difficult topics: Forbidden Topic in Health Policy Debate: Cost Effectiveness. We can’t do everything for everyone – but in our current system, we don’t discuss how tradeoffs are made, thus all but guaranteeing that they are made in an arbitrary and inefficient way.

Last week, we talked about an editorial in Health Affairs Why I Oppose Payment Reform. This week, part 2 of the editorial was published: How To Succeed At Payment Reform (By Really Trying) “Given the concerns I raised in my prior post, I believe payment reform will only achieve its intended goals if it occurs in a broader context that includes other strategies — for example, defining spending targets and launching initiatives to improve health outcomes by reallocating resources to the social sector.” Or to put it another way, we need extreme solutions to these extreme problems.

CMS Announcements
As I've complained about before, figuring out a taxonomy for this newsletter is hard. Many items could go in multiple categories, yet I don’t want so many categories that each item ends up in a category of one (kind of defeats the purpose). This week, throwing up my hands I’m including this special category to handle a flurry of year end announcements from CMS.

Medicare Cuts Payments To 721 Hospitals With Highest Rates Of Infections, Injuries “In its toughest crackdown yet on medical errors, the federal government is cutting payments to 721 hospitals for having high rates of infections and other patient injuries, records released Thursday show. Medicare assessed these new penalties against some of the most renowned hospitals in the nation, including the Cleveland Clinic, Brigham and Women’s Hospital in Boston, the Hospital of the University of Pennsylvania in Philadelphia and Geisinger Medical Center in Danville, Pa.”

More hospitals to get bonuses than penalties in 2015 under value-based purchasing “A total of 1,698 hospitals will have their Medicare payments boosted in 2015, 467 more than in 2014, according to a Modern Healthcare analysis of data the CMS posted Wednesday. …  A total of 1,360 U.S. hospitals will have their Medicare payments docked next year.”

Details about the previous two items can be found on the CMS website there: Fiscal Year 2015 Results for the CMS Hospital-Acquired Condition Reduction Program and Hospital Value-Based Purchasing Program.

But wait, there’s more!

Public reporting of 2013 quality measures on the Physician Compare and Hospital Compare Websites “CMS has added new quality data to the Physician Compare website. Additionally, CMS has updated quality measures on the Hospital Compare website and released data on new measures. These websites are part of an Administration-wide effort to increase the availability and accessibility of information on quality, utilization and costs for effective, informed decision-making.”

And finally: Providers balk as CMS announces penalties for 2013 EHR issues “A CMS announcement that many doctors will see their 2015 Medicare payments cut by 1% for failing to meet federal electronic health-record incentive-payment program standards has provoked strong reactions from physician and hospital groups.”  However, note that this was a voluntary program: “More than $25.7 billion in EHR incentive payments were made between early 2011 and Oct. 1 this year, including about $10.3 billion to physicians and other EPs, and $15.4 billion to hospitals, CMS data show. More than 414,000 physicians and other EPs, and 4,695 hospitals have been paid to date.”

Medicaid
CMS released new Medicaid enrollment data this week: Medicaid and CHIP Enrollment Milestone Achievement: Enrollment Grows by Approximately 9.7 Million Additional Americans “As of October 2014, approximately 9.7 million additional Americans were enrolled in Medicaid and CHIP – a 17 percent increase over the average monthly enrollment for July through September 2013, the months before the Marketplaces first opened.”

The NY Times took a look at the numbers, focusing on states that had not expanded Medicaid: Medicaid Rolls Surge Under Affordable Care Act. We’ve talked before about the “woodwork” or “welcome mat” effect – that just the talk about health coverage will get some to apply for Medicaid who had not applied before even though they were already eligible. These numbers show its impact. A side note, when looking at the chart in the article you’ll see Maine is not included. According to the footnote, Maine did not report enrollment figures to CMS. But while we don’t have exact numbers, we do know that here in Maine, enrollment is now under 300,000 for the first time in many years as people who were terminated earlier this year lose their transitional benefits.

That brings up the topic of Medicaid expansion – lots of news this week from states who have not yet expanded, and some from those who have.

We’ll start with some observations from Drew Altman about the increasing number of Republican Governors who opposed the ACA that are now considering expansion: Medicaid Expansion in Red States “These days, momentum in the states lies with pragmatism over conservative ideology and anti-Obamacare sentiment–that is, provided the details of the deal between the administration and these states are just right. But momentum could swing back, depending on developments in Congress and the Supreme Court.”  The Washington Post also observed that Three Republican governors have now endorsed the Medicaid expansion since the midterms.

And talking about swinging back, one of the earliest examples of a “red” state expanding, the original private option state Arkansas, is now considering rolling back its expansion: Arkansas' model Medicaid experiment in jeopardy.

Before continuing, let’s remember that there is a difference between a Governor stating that they will expand under certain conditions, and CMS accepting those conditions by granting a waiver. Secretary Burwell has said she will speak to any Governor that wants to talk, but keep in mind what George Burns had to say about prayers in the movie Oh God: I answer all of them, but sometimes the answer is no.

To date, waivers have been approved in Arkansas, Iowa, Michigan and Pennsylvania. Despite the ongoing conversations, nothing has yet been approved for Alaska, Tennessee, Utah or Wyoming.

Here is some of the state specific coverage:


Medicare
Need another reason to be concerned about the future of Medicare?  Here you go: Paul Ryan's bid to overhaul Medicare to resurface in new Congress. His plan is to replace the program with vouchers for private coverage.

But we see this week yet again, that the benefit of private Medicare plans (Medicare Advantage) often goes to the insurers, not the beneficiaries: How much do beneficiaries gain from higher Medicare Advantage payments “One of the main arguments in favor of Medicare Advantage is that competition provides the greatest value to beneficiaries. Even if one believes that to be the case, according to this study, Medicare Advantage may not achieve levels of competition to come close to fulfilling its potential. Beneficiaries are supposed to be better off under competition. The less competitive the program, the less clear it is that they are.”

Drugs
In 2012 there was a meningitis outbreak that killed 64 people. It was traced to tainted drug injections made by a “compounding pharmacy”. This week, Compound Pharmacy Owners and Employees Arrested for Meningitis Outbreak “The most serious charges were made against Barry Cadden, a co-founder, and Glenn Chin, a supervisory pharmacist who oversaw the sterile room, who were charged with 25 counts of second-degree murder for causing the deaths of patients in seven states. Cadden and Chin face a maximum of up to life in prison if convicted on all counts.”

In light of the charges, Modern Healthcare asked the question: Are compounding pharmacies safer now? The answer is yes, partially due to a law passed by Congress in 2013 as a result of the incident.

Also in legal arena a Judge halts Alzheimer's drug swap until July. There is a common practice whereby a pharmaceutical firm takes a drug who’s patent is about to expire, tweaks the drug (such as taking a two pill a day drug and making it one pill a day), takes out a new patent and then removes the old drug from the market. That means the patient is forced to change the way they use the drug, then when the generic comes out a few months later it is harder to get individuals to switch to it, since it represents another “change”. The ruling could have a sweeping impact on the ability of the drug company to remove the original drug from market (Court Rules on Alzheimer’s Drug: Decision Could Reduce a Common Industry Practice) thus making it easier to switch to the generic when it is available.

System Transformation
Thirteen months after his nomination, this week Vivek Murthy was confirmed as Surgeon General. His nomination was contentious because he had the audacity to say that guns (and the injuries they cause) are a public health issue. In part due to Ted Cruz’s objections to the Cromnibus (see last week’s issue), his nomination was finally brought to a vote by the full Senate and approved (Senate Confirms Gun-Control Advocate as Surgeon General - Vivek Murthy became the nation's top doctor Monday, but only after a protracted fight over firearms). Here are more details on the man and what a Surgeon General actually does: Vivek Murthy is the new surgeon general. Who is he, and what the heck is his job?

Also in the news this week was a historical change in the dynamic of US-Cuban relations. Why am I talking about that in a health policy blog?  Primarily because of something called the Cuban Paradox. That is the term used because while Cuba is considered a poor country, their health system is one of the best in the world when measured by the health of the population. That begs the question, Can Cuba Escape Poverty but Stay Healthy?  Also, this piece takes a look at how both countries health care systems can benefit from improved relations: Renewed U.S.-Cuba relations could impact both nations' healthcare

The Washington Post takes a deep dive into end-of-life care: ‘Warehouses for the dying’: Are we prolonging life or prolonging death? ““I think if someone from Mars came and saw some of these people, they would say, what have they done to deserve this punishment?” said Marik, gesturing to the surrounding rooms. “People might say we are prolonging life, but we end up prolonging death.”” An important piece of the puzzle is palliative and hospice care. Here are some thoughts on each: How to introduce palliative care to patients and Too Little, Too Late For Many New Yorkers Seeking Hospice.

Two developments in patient care worth noting this week: Belly Fat Tied to Sudden Cardiac Death and For First Time, Treatment Helps Patients With Worst Kind of Stroke, Study Says.

On the technology front, a mind boggling look at the near future: Fantastic Voyage: Tiny Sensors May Soon Monitor Seniors’ Medicines From Inside and a reminder that technology can also help with some of the more mundane tasks: Doctors no match for computers at accurately recording patient symptoms, study finds

A new study out this week looked at Shared Decision Making And The Use Of Patient Decision Aids. It reinforces the point that we still have a long way to go to achieve the goal of providing: “the care patients need and no less; the care they want and no more.”  Handing someone a PDA (no not a public display of affection or a personal digital assistant, a patient decision aid) is NOT shared decision making. After the patient reviews the material there needs to be a two way conversation with the provider if it is truly going to be a shared decision.

And finally, while we've picked on Dr. Oz before, it’s both appropriate and fun. So let’s end the year with a classic and do it one more time: Half of Dr. Oz’s medical advice is baseless or wrong, study says

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"
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