Friday, January 30, 2015

That Was The Week That Was - Issue 46

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

New Kaiser survey data, subsidy case developments, enrollment numbers, HHS going all in on payment reform, CBO projections, Indiana expands Medicaid while trying to call it something else, measles and more.

But first, a lost puppy finds its way home. OK, everyone in a good mood now?  Here we go.

ACA: Opposition/Court Cases
This week, an op-ed was printed in the Washington Post with the provocative title End Obamacare, and people could die. That’s okay. The argument was that society makes choices all the time that lead to deaths. Needless to say, some took issue with the piece: “He fails not because conservative health policy ideas are inherently immoral, but because he must gloss over the fact that the right’s current approach to implementing them is abominable.” (The Conservative Plan to Repeal Obamacare Is Insanely Immoral) and then my personal favorite: “Some people think it would be moral to force the staff of the American Enterprise Institute to engage in gladiatorial bouts to the death for our amusement.” (the author of the original piece works there) (Repealing Obamacare Would Be Extremely Immoral).

The Senate panel unanimously OKs bill letting employers exempt vets from sparking health coverage. This is a feel good bill that will have little real impact. It says that vets don’t count when calculating the number of employees relative to the mandate. It has already passed unanimously on the floor of the House and is supported by the White House. However, the floor vote in the Senate may still get messy.

Republican leadership appeared on 60 Minutes for a wide ranging discussion of their plans. Not surprisingly the talk turned to health care when this happened: Boehner and McConnell Bomb On 60 Minutes When Asked For GOP Alternative to Obamacare “Republicans have had almost six years to come up with an ACA alternative. They have had even longer to come up with a plan to reform health care. The Republican plan is to return the country to a system where tens of millions of Americans lack access to health care, and those with insurance are one medical crisis away from bankruptcy.”

And speaking of not having a plan, Republicans Are At A Loss On What To Do If SCOTUS Nixes Obamacare Subsidies This quote from a Republican staffer is telling: “"It's an opportunity that we've failed at for two decades. We've not been particularly close to being on the same page on this subject for two decades," said a congressional Republican health policy aide who was granted anonymity to speak candidly. "So this idea — we're ready to go? Actually no, we're not."”

Now they are trying to force themselves to come up with something: House Bill To Repeal Obamacare Will Tell Committees To Write GOP Alternative

All this talk about alternatives comes as we near the SCOTUS case on the availability of subsidies on the Federal marketplace. This week the Administration filed its brief with the court: ACA clear on allowing subsidies, Obama administration tells high court “The administration, however, in its new brief, makes a number of arguments, including that the law is clear, when read fully, in allowing tax credits in all states. The brief cites a number of other places in the law that the administration says prove that the credits were meant to be available to individuals in all states.”

Also this week, more amicus briefs were filed: “Health insurance companies and hospitals mounted an aggressive defense of Obamacare's insurance subsidies Wednesday, warning the Supreme Court that eliminating the payments would be "grossly inequitable" to millions of Americans.” (Can The Health Care Industry Save Obamacare? Hospitals and insurance companies are coming to the law's defense before the Supreme Court.)

This week there was lots of discussion about how weak the case against subsidies is. A key point made is that if the law was written with no subsidies on the Federal Marketplace as an inducement for states to create their own, then the states should have known about the threat. That was not the case: Republican state officials cast doubts on anti-Obamacare lawsuit “Several state officials who were directly involved at the highest levels in early deliberations over setting up state exchanges — all of them Republicans or appointees of GOP governors — have told me that at no point in the decision-making process during the key time-frame was the possible loss of subsidies even considered as a factor. None of these officials — who were deeply involved in figuring out what the law meant for their states — read the statute as the challengers do.”

Also, if that were the case you would expect Republicans in the House would have known about it: Republicans Know Their Obamacare Case Is Bogus. Here's the Proof. “But that assumption didn't hold in April 2011. Something else must explain CBO's 1099-repeal score, and the Republican votes that followed it. What we have in the form of this bill is clear evidence that everyone who voted for it (including every single Republican, save the two GOP congressmen and one GOP senator who weren’t present) understood the Affordable Care Act to provide subsidies everywhere.”

Since we’re not talking about the Founding Fathers, we can actually ask some of the players in passage of the law. A key one is former Nebraska Sen. Ben Nelson: “Nelson, a Democratic holdout as Congress debated the bill, insisted that states take the lead in establishing the exchanges. And the challengers use that to support their theory that Congress was using the tax credits to induce states into establishing the exchanges, rather than having the federal government do it. But Nelson, who announced his retirement in 2011, speaks for himself in a brief filed by Democratic congressional leaders and others. “I always believed that tax credits should be available in all 50 states regardless of who built the exchange, and the final law also reflects that belief as well,” Nelson wrote in a letter to Sen. Bob Casey (D-Pa.) who sought Nelson’s view.” (Supreme Court case on key Obamacare provision takes up this senator’s account)

To sum up, The Latest Obamacare Challenge Has Entered 'X-Files' Territory “That’s where we are today. These conservatives have come a very long way. But there’s something conspicuously missing from this widely shared conviction: any evidence of the intent on which their entire argument rests. The truth is out there.”

In the height of irony those responsible for the potential problem are asking how it would be fixed: GOP to White House: What's your ObamaCare backup plan? “GOP lawmakers have a big question for President Obama about the upcoming Supreme Court case that could undo much of his signature healthcare law: What happens if we win?”

An issue with a legislative fix after SCOTUS rules is that once the ruling occurs, the CBO will change their baseline budget. Putting back what the court took away would “cost” $350 billion, a bill Congress is unlikely to pay. (King v. Burwell: The Prohibitive Cost of Any Congressional Response to a Ruling Against the Affordable Care Act)  Of course this problem goes away if Congress fixed the law before the case was heard, thus making the case moot. But that’s not likely to happen.

Unfortunately, there are no easy administrative fixes if the court does rule against the subsidies: What Obama Can Do If SCOTUS Cripples Obamacare “"There are no administrative fixes that are realistic," said Neera Tanden, president of the liberal Center for American Progress.” We don't believe there's any administrative fix." … Without a fix in Congress or a good administrative option, the only solution would be to convince the states to set up their own exchanges. That would involve convincing Republican governors and Republican-controlled state legislatures, all of whom have already refused to set up their own exchanges once, to cooperate.”

Outside the beltway, things are a bit more rational: If Supreme Court Rules Against Insurance Subsidies, Most Want Them Restored “But if the court were to invalidate subsidies in the federally run states, 64 percent said Congress should restore them, and 59 percent said states should create their own exchanges.” (From this month’s Kaiser survey discussed in more detail below.)

But it’s inside the beltway we have to worry about, and last night we received this not surprising message: Republicans to Block Legislative Fix to Health-Care Law “Congressional Republicans say they won’t move to preserve consumers’ health insurance tax credits if the Supreme Court strikes them down, raising the stakes in the latest legal challenge to the Affordable Care Act.”

ACA: Polls
This month’s Kaiser Tracking Poll is out (Primary Source: Kaiser Health Tracking Poll: January 2015) In addition to the subsidy question discussed above, one of the important findings was: “With less than a month left in this year’s open enrollment period, most uninsured are unaware of the deadline to enroll and a substantial share remains unaware of the financial assistance available to help eligible people buy insurance.” 

Another survey from Kaiser looked specifically at the uninsured: Some Seeking Insurance Told They Didn’t Qualify, Others Balked At Cost, Poll Finds “Nearly half of Americans lacking health insurance during the first year of the health law’s marketplaces appeared to be eligible for government assistance, but two-thirds of them said they found the health plans too expensive or were told they didn’t qualify, according to a survey released Thursday.” Primary Source: Adults who Remained Uninsured at the End of 2014.

One puzzling result: “More than one-third of people who are still uninsured under Obamacare -- but appear to be eligible for coverage -- were told that they were not eligible for health insurance under the law, according to a new report. … "People may have been confused about what they were being told," Levitt said. "Or, they may have been told they were ineligible for marketplace coverage but eligible for Medicaid, or vice versa, and were confused by that or didn’t follow up."” (WTF? Experts Stumped By New Finding On Obamacare And The Uninsured)

ACA: Enrollment
In addition to the weekly report, this week HHS released a more comprehensive look at enrollment including both the Federal and State marketplaces: Nationwide 9.5 million consumers are signed up for Health Insurance Marketplace coverage “Today’s report includes data for individuals who selected or were automatically reenrolled in coverage through Jan. 16 for the 37 states using the HealthCare.gov platform, and through Jan. 17 for the states and Washington, D.C. using their own Marketplace platforms.”

Obamacare Nears Enrollment Goal  “The total includes new sign-ups and renewals of 2014 coverage, as of Jan. 16. It is the first full picture of insurance exchange sign-ups for 2015, including both the federal and the state marketplaces. The Obama administration hasn't met its enrollment goal yet, but it's close. The Health and Human Services Department said it aims to have between 9 million and million enrolled in exchange coverage this year. Open enrollment closes Feb. 15.”

For those interested in rankings, acasignups.net has tried to answer the question Which states are doing the BEST this year? He compares the states across 4 different benchmarks.

You can find the weekly report here: Open Enrollment Week 10: January 17, 2015 – January 23, 2015. Many areas saw a bit of a lull following the 1/15 deadline for 2/1 coverage. That should change as momentum builds to the 2/15 end date of this year’s open enrollment period.

And finally, a look at how Obamacare advocates refine their pitch to millennials “Obamacare advocates stress that the lower-key strategy reflects what has been learned about their target group’s response to the health care law. A more direct, organic conversation, they say, works better than some broad, national push relying in part on pop stars, pro athletes or other big names.”

ACA: Taxes
Is everybody ready for tax-time?  This year there will be something new since your tax-return is where both the individual mandate is enforced and premium subsidies are reconciled. You can read a good overview here: Here's How Obamacare Is Going To Affect Your Taxes

While for many it will simply mean checking a box indicating you have health insurance, the U.S. Government Says Obamacare Could Affect Up to 29 Percent of Taxpayers: 2-4% expected to pay a penalty, 3-5% could have to reconcile the federal and 10-20% percent are expected to use their tax filings to seek exemptions from the law's coverage requirements

Given this is new to all of us, and that many people don’t actually do their own taxes, HHS to work with non-profit organizations and tax preparers to help consumers understand the intersection of taxes and health care “U.S. Department of Health and Human Services’ Secretary Sylvia M. Burwell announced today that HHS is collaborating with a wide range of non-profit organizations and some of the nation’s largest tax preparers to ensure that the public understands how health care and their taxes intersect.” Link includes list of resources

Another development related to taxes this week: IRS Waives Penalties for Late Payments Linked to Obamacare “The U.S. Internal Revenue Service will waive some penalties for taxpayers who owe taxes because of Obamacare. … The IRS will waive penalties for making that payment late or for failing to pay estimated taxes throughout 2014.”  Note that what is being waived is NOT the penalty for not having insurance nor is it the amount that might need to be paid back once subsidies are reconciled. For the details as always we turn to Tim Jost (who covers some additional developments as well in this posting: Implementing Health Reform: ACA-Related Tax Penalties Waived; High Court Turns Back Oklahoma AG

ACA: Other
While in some ways insurers and consumers interests are more aligned post-ACA, this is not always the case. It seems clear now that some insurers are Using Drugs to Discriminate “The complaint alleges that insurance companies in some states are structuring their drug formularies in such a way as to discourage patients with HIV from signing up. “ Primary Source: Using Drugs to Discriminate — Adverse Selection in the Insurance Marketplace.

Bad behavior does not seem to be needed as those playing by the (new) rules are doing will under the ACA: Health insurer stocks have crushed market averages since Obamacare passed “Back when Obamacare became law, there was lots of worry from the health care industry about how a new layer of government bureaucracy would be terrible for business.” The opposite happened “Health plans have handily outperformed the S&P 500 during Obamacare's implementation. And it's easy to see why: the health care law required Americans to purchase the products they sell or pay a penalty. Enough healthy people have apparently turned up — and insurers are doing great in the post-Obamacare landscape.”

Last week we reviewed a report regarding the use and safety of consumer information on healthcare.gov. In response to those concerns, the administration quickly took action: Added Protections For Consumer Information On Health Website “The Obama administration appears to be making broader changes to protect consumer information on the government's health insurance website, after objections from lawmakers and privacy advocates. … An independent analysis of the health care website, released Saturday, showed that the number of embedded connections to private companies had dropped from 50 to 30.”

Part of the ACA that hasn’t received much focus is the requirements for non-profit hospitals. Those rules have now been finalized: Additional Requirements For Charitable Hospitals: Final Rules On Community Health Needs Assessments And Financial Assistance “Health – not just health care – needs. The final rule makes clear that a CHNA can assess not only significant unmet need for health care, but also significant health needs arising from social conditions such as inadequate access to proper nutrition and housing and “the mitigation of social, environmental, and behavioral factors that influence health, or emergency preparedness.”  In response to extensive public health comments, the final rules thus embrace an approach to the CHNA process that prioritizes “not only the need to address financial and other barriers to care but also the need to prevent illness, to ensure adequate nutrition, or to address social, behavioral, and environmental factors that influence health in the community.” This strong signal that the CHNA process is about community health — not simply access to health care — is reinforced by IRS efforts in recent years to clarify that community benefit spending can encompass not only subsidized access to health care but also investments in community health improvement and community building that is linked to community health.”

Payment Reform
On Monday (1/26/15) HHS made a “historic” announcement regarding how Medicare will change the way it pays for medical care. I wrote a separate posting detailing the announcement and some of the initial reaction, you can read it here: HHS announces they are going for Better, Smarter, Healthier

Below I’ll briefly review the announcement and some of the follow-up analysis along with a companion announcement by a group of private payers.

“…Health and Human Services Secretary Sylvia M. Burwell today announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” (Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value)

The basic idea is to finally move away from the fee-for-service payment structure. The announcement sets out admirable goals and is gutsy in that it lays out specific benchmark numbers by which success can be judged. But as is to be expected with any announcement of this scope, there are elements to be admired and elements to be questioned.

There was also a piece by the Secretary in the New England Journal of Medicine: “The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.” (Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care)

This piece, while calling it: A Courageous First Step includes a cautionary note about moving forward: “Many have dipped a timid toe, or hedged their bets with low-regret moves like buying up practices and forming organizations that are Accountable Care Organizations (ACOs) in name only. Unfortunately, this strategy is already too widespread, and likely to grow as long as large organizations are allowed to continue in “one-sided” (upside only) shared savings models, as recently proposed by CMS. It’s also a major reason why so few hospital-sponsored ACOs have actually achieved savings bonuses. Defensive moves by hospital systems provide a veneer of action, while consolidating regulator-blessed market dominance that can raise local prices without improving quality at all.”

And this: ““We still have very little evidence about which payment methods are going to be successful in getting the results we want, which are better quality care and more affordable care,” said Suzanne Delbanco, executive director of Catalyst For Payment Reform, a California-based nonprofit that has been tracking the spread of alternative payment models in the private sector. “We’re just wanting to avoid a situation where a few years from now, where we’ve completely gotten rid of fee-for-service, we don’t want to wake up and say, ‘Oh my gosh, we did it and we’re no better off.’”” (HHS Pledges To Quicken Pace Toward Quality-Based Medicare Payments)

But it wasn’t just HHS making big announcements re payment reform: Industry Group to Back Results-Focused Care The coalition said it was committed to finding a way to change the financial incentives, moving the bulk of payments to so-called value-based arrangements by 2020, in which cost and quality would be part of the equation. Many health care systems and insurers are already experimenting with such arrangements. The announcement comes on the heels of a similar vow by Health and Human Services Secretary Sylvia M. Burwell on Monday. She said half of all traditional Medicare payments would be based on quality of care or value by 2018. … While largely rhetorical, the commitments by Medicare and the private sector group reflect a fundamental shift in thinking. “We’re very much aligned and share a common goal here,” said Fran S. Soistman, an executive vice president for Aetna, who said the federal government’s announcement “bodes well” for the overall effort.”

One element of value purchasing is reference pricing. Here’s a look at how effective that has (and hasn’t) been so far: Reference pricing, what could possibly go wrong?

Here is a good overview reminding us that so far these goals are aspirational. Measuring quality is hard and to date providers have been reluctant to share risk: “Gilfillan said the task force members are committed to revamping how hospitals and doctors are paid even if they're not entirely sure how to do it. “We go out and we set ambitious goals that are consistent with our commitment to the great healthcare providers and we don't know everything we need to know about how to get there,” he said. … The declarations, however, leave many questions unanswered, raising doubts about whether meeting the targets will accomplish the desired improvements in quality and efficiency. Medicare's newly announced push to rapidly adopt accountable care and other new payment models was met with concerns from health policy experts that Medicare incentives are tied to weak measures of quality.” (Where healthcare is now on march to value-based pay)

My bottom line, while we must move away from fee-for service, the data is not yet clear on exactly where we should be going. The announcements this week are great steps forward, but we need to remember that the new ways to compensate providers are still being refined. In the end the system may need even more radical changes than those currently being discussed to achieve the stated goals.

And finally, two reminders from today’s headlines that that change is hard. First: Medicare Payments Surge for Stents to Unblock Blood Vessels in Limbs  Just as progress is being made to reduce unnecessary cardiac procedures we see a spike in unnecessary peripheral revascularizations as some providers find a way to make up for lost revenue with procedure of questionable value.

Second: “New reports show that two big experiments run by the health law’s innovation lab, known as the Center for Medicare & Medicaid Innovation, delivered mixed early results in enhancing primary care. The programs reduced expensive hospital visits in some cases but struggled to show net savings after accounting for their cost.” (Mixed Results For Obamacare Tests In Primary-Care Innovation)

Costs

The CBO released new projections this week. They included several new numbers related to the ACA. I’ll let the numbers speak for themselves:

“Meanwhile, the CBO said that the cost of the Affordable Care Act continued to come in substantially below the March 2010 estimates. Because the program gets more expensive over time, the 10-year cost estimates have risen. But costs compared year by year remain lower.

In March 2010, the CBO and Joint Committee on Taxation projected that the ACA would cost the federal government $7billion during fiscal years 2015 through 2019. The newest projects put the cost at just $571 million over those years, about 20 percent lower than the original estimates, the CBO said in its report. The latest projections for the cost in 2019 are $132 billion, or 23 percent less than the original projection.

The CBO said that the ACA had reduced the number of uninsured people by 12 million in 2014 and would by 19 million in 2015. It said that between 2016 and 2025 the legislation would reduce the number of uninsured by 24 million to 27 million people.

That would still leave 31 million people uninsured in 2025, about 30 percent of them “unauthorized immigrants,” about percent in states that have chosen against expanding Medicaid coverage, 15 to 20 percent of whom would be eligible for Medicaid and choose not to use it, and about 40 to 45 percent of whom would have access to insurance but choose not to use it.” (CBO: Interest on federal debt will triple over coming decade)

Also on the cost front, in Drew Altman’s latest he discusses the limitations of price transparency in curbing cost problems. This sentence will sound familiar to my regular readers: “While consumers urgently need better price information, it’s hard to see that being a complete antidote to massive price variation.” (Why Data on Health-Care Price Variation Doesn’t Itself Solve the Problem) Or in other words, cost transparency is a necessary but not sufficient condition to stemming out of control prices.

Medicaid
Lots of Medicaid news this week. Let’s start with a question: Do Low-Income Consumers In Medicaid Opt-Out States Pay More Out Of Pocket? “Under Medicaid, far fewer of these adults’ family health costs would exceed percent of their income: 6.0 percent, compared to 17.1 percent under silver exchange plans.” No surprise there, (but data!) evidence that Medicaid is less burdensome than private insurance.

Keep that in mind as we turn to the news out of Indiana, where Gov. Pence gets federal OK for Medicaid alternative. “Everyone on the Healthy Indiana Plan will be required to make a contribution ranging from $1 to about $27 per month, depending on income. This money, which amounts to about 2 percent of family income, funds a $2,500 Personal Wellness and Responsibility, or POWER, account, which functions like a Health Savings Account.”

That’s some of the complexity of the plan that received a waiver from HHS. You can read more of the details here: Press release: CMS and Indiana Agree on Medicaid Expansion.

Whatever you do, don’t call this a Medicaid expansion (even though that’s exactly what it is): “"Republicans are reticent to embrace expansion of entitlement programs, and thus they are quick to avoid calling it Medicaid expansion," Caroline Pearson, vice president at Avalere Health, an independent consulting firm, told TPM in an email. "They also use branding with other program and waiver names to further distance themselves from the Obamacare Medicaid expansion."” (Republican Rhetorical Gymnastics On Medicaid Expansion Are Getting Crazy)

Why so afraid of the name, one reason is Republican Party politics: Another Republican Governor Has Accepted the Medicaid Expansion—and He Might Run for President “The early consensus is that, if indeed Pence decides to run, this decision would cause him trouble in the GOP primary. But the issue poses a dilemma for the Republican Party more broadly, especially its hopes of recapturing the White House.”

But Pence would not be alone: “Should Pence decide to run for the 2016 Republican nomination, he could join other rumored hopefuls Chris Christie of New Jersey and John Kasich of Ohio as governors who bucked party orthodoxy to accept Obamacare Medicaid expansion funding.” (More evidence that conservative Republicans are caving to Obamacare).

When the ACA was passed The Goal Was Simplicity; Instead, There’s a Many-Headed Medicaid “But advocates for Medicaid beneficiaries worry that the added complexities of the new programs — with premiums and co-payments and other requirements — will be a burden for the program’s poor beneficiaries, and a hassle for state officials and medical providers to oversee. “It’s hard to imagine feeling nostalgic for Medicaid as an administratively simple program,” Ms. Alker said. “But I’m beginning to feel that way.” Some people have argued that managing all the rules and collecting premiums and payments may cost a state more money than it will earn. And there are studies that show that premiums, in particular, tend to discourage low-income people from signing up for coverage and seeking the care they need.””

Unfortunately we’ve seen elsewhere that for this population, premiums will suppress enrollment: “Premiums aren’t supposed to be a means to discourage people from gaining access to the health care system. But that seems to be how they’re functioning in Medicaid.” (Medicaid Gives the Poor a Reason to Say No Thanks “)

We have also seen time and time again, the fallacy of cost-sharing being a useful tool. Yes it may suppress care, but it suppresses needed care as much as unneeded care: People With Chronic Illness Fare Worse Under Cost-Sharing  “What we see from this study is that families with higher levels of cost-sharing were significantly more likely to delay or avoid going to the office or emergency room for their child’s asthma. They were more likely to have to borrow or cut back on necessities to afford care. They were more likely to avoid care. This isn’t a good outcome. We’re talking about children with a completely manageable chronic condition who are being hampered by cost-sharing. That’s not what cost-sharing is supposed to do.”   …   “Plans that increased co-pays saw two additional hospitalizations and 13 more days in the hospital per 100 people. These increases were worse in older people who lived in low-income areas, and among those who were documented to have high blood pressure, diabetes or a history of heart attack.”

So bottom line, while many would say any expansion is better than no expansion, this one pushes the limits.

Another unique aspect of the plan is that even after the 100% Federal reimbursement steps down to 90%, there will be no added cost to the state: “Under the agreement, Indiana will pay for its share of the expansion costs beginning in 2017 with hospital fees and a cigarette tax. … “I think this raises the level of interest in looking at these issues in states that have not expanded Medicaid,” said Joe Antos, a health economist at the conservative American Enterprise Institute. “Lawmakers in Texas may not be influenced but there are other states that will want to know more.”” (Indiana Medicaid Expansion May Tempt Other GOP-Led States)

Also news this week in other states. 2017 will bring with it the 1332 waiver program that is part of the ACA. These waivers allow states to drastically change the way they comply with the law (with certain qualifications regarding not reducing coverage, etc.). As part of his speech last week encouraging extension of the private option for 2 years, Arkansas Gov. Hutchinson said the state should start planning its waiver program. Here is a look at the Arkansas marketplace report on the topic: Arkansas Health Insurance Marketplace report examines 1332 waivers, potential tool for future reform. This is the first specifics we’ve seen about preparing a waiver application, there will be a lot more on this in the coming months.

And finally, it looks like Wyoming headed toward Medicaid expansion “Mead initially opposed Medicaid expansion under the Affordable Care Act, and the state joined a Republican-backed lawsuit aimed at overturning the health law. But, he said in a recent interview, now that the Supreme Court has upheld the law, Wyoming should take advantage of federal money that would cover uncompensated care that costs state hospitals more than $100 million a year.”

Measles/Vaccination
Lots of coverage this week as the number of measles cases continued to spread. We saw Arizona tracking up to 1,000 potentially exposed to California-linked measles virus. In California we saw Demand for Measles Vaccine Sends Crowds Even to Anti-Vax Docs “Demand for measles vaccines has overwhelmed some pediatricians in California — even the doctor best known for treating anti-vaccine activist Jenny McCarthy's son.”

At the same time, Kaiser calling parents who refused to vaccinate against measles. They thought that by next week they will have reached out to everyone in their records who was not vaccinated. All the attention may have another benefit, Forget ‘anti-vaxxers.’ The Disney measles outbreak could change the minds of an even more crucial group. “But doctors believe the current outbreak could change the minds of a less-known but even larger group: parents who remain on the fence about the shots.”

But what should be done moving forward?  Sick Child’s Father Seeks Vaccination Requirement in California. Others are putting forward a more radical plan: Measles Is Spreading And Kids Are At Risk. Sue Parents Who Didn't Vaccinate? Absolutely. When all else fails, sue! Sounds funny, but the article does a thorough review of the topic and comes to the conclusion that it may be the only way to motivate some people.

On a more moderate note, this reminder from Melinda Gates that we don’t know how good we have it: "We take vaccines so for granted in the United States," Gates told the Huffington Post in a prerecorded interview published on Thursday. "Women in the developing world know the power of [vaccines]. They will walk kilometers in the heat with their child and line up to get a vaccine, because they have seen death. [Americans have] forgotten what measles deaths look like.""  (Melinda Gates has the perfect response to the anti-vaccine movement)

There are some who argue that more than those opting out, the bigger problem is access: The Real Reason Kids Aren't Getting Vaccines. While that might be a factor, this startling fact says that access doesn’t have to be a problem: Mississippi – yes, Mississippi – has the nation’s best child vaccination rate. Here’s why.  “It’s tough being a child in Mississippi. The state has the nation’s worst rates for infant mortality and low-weight newborns. Its childhood poverty rate ranks as the nation’s second worst. Overall, the residents of Mississippi are the unhealthiest in the country. But there is one notable exception to these dour health stats: Mississippi has the highest vaccination rate for school-age children. It’s not even close. Last year, 99.7 percent of the state’s kindergartners were fully vaccinated. Just 14 students in Mississippi entered school without all of their required shots. … The secret of Mississippi’s success stems from a strong public health program and — most importantly — a strict mandatory vaccination law that lacks the loopholes found in almost every other state.”

So we see it can be done, even in a state with few resources.

Other coverage looked at how the disease may have started, in both the current case and with this article, in an outbreak from last year: How an Amish missionary caused 2014's massive measles outbreak.

But at the end of the day, the initial case is not the issue. For now there will always be a way for these outbreaks to get started, it’s what happens next that we need to focus on: This is how outbreaks occur. It isn’t complicated. “1) Someone travelling/living abroad contracts the disease and comes to the US 2) Other people who are susceptible to the disease come into contact with them here at home 3) Those people contract the disease 4) Go back to step 2. That’s it. It doesn’t matter if the person from step one was an illegal immigrant, a doctor working overseas, or an Amish Missionary. Since we can’t control what other countries do, and we live in a world where people travel, (1) is going to occur at some point.”

So what we have to do is get those vaccination rates up, plain and simple.

Ebola
“There's finally good news on the ongoing struggle to stamp out the world's worst Ebola outbreak: the number of new cases is falling quickly. Fewer than 100 Ebola cases were discovered in West Africa last week: there were 30 in Guinea, four in Liberia, and 65 in Sierra Leone. The World Health Organization says the epidemic has entered its "second phase," and that the global community can now focus on slowing transmission to get to the finish line. “ (There are fewer than 100 Ebola cases in West Africa. Is the end in sight?)

System Transformation

Efficacy/Quality of Care
The President mentioned this in his State of the Union address. Today (1/20/2015) he attached specific numbers to his proposal: Obama Wants $215 Million For 'Precision Medicine' Plan “The vast majority of the proposed funding would go to the National Institutes of Health: $131 million, plus another $70 million for the National Cancer Institute, which is part of NIH. Many of the biggest advances in precision medicine, also known as personalized medicine, have come in the field of cancer treatment, and cancer would be a major focus for Obama's new initiative as well.”

One of the reasons an initiative like this is needed is because “In truth, medical care is often far less effective than most believe. Just because you took some medicine for an illness and became well again, it doesn’t necessarily mean that the treatment provided the cure.” (Can This Treatment Help Me? There’s a Statistic for That) As this piece points out, we have tools to understand this (number needed to treat!), they are just not used regularly.

In addition to treatments that are not effective, we also suffer from medical errors. A topic we’ve covered before, but as Vox begins a yearlong project with ProPublica on the topic, they provide this comprehensive overview on how bad the situation truly is: Medical errors in America kill more people than AIDS or drug overdoses. Here's why.

And then, in addition to errors (which are by definition unintentional) we have those who intentionally mislead: Read this before you ever believe another guest on the Dr. Oz Show.

End of Life Care
It’s never too soon to talk about what your priorities are when it comes to health care and extreme measures. Here are The 6 questions every good doctor should ask you to help start the planning.

Similarly we are reminded that Learning About Hospice Should Begin Long Before You Are Sick. This is a great overall review of hospice care including questions to ask potential providers. “But experts in end-of-life care say most Americans need to start thinking about hospice long before the final six months is near. As the American Cancer Society notes on its website: “One of the problems with hospice is that it’s often not started soon enough. Sometimes, the doctor, patient, or family member will resist hospice because he or she thinks it means you’re ‘giving up,’ or that there’s no hope. This is not true. If you get better or the cancer goes into remission, you can leave hospice and go into active cancer treatment.””

On a less crucial but nonetheless important note, another part of planning concerns social media accounts: What I'll Do With My Parents' Facebook After They Die. Understanding people’s wishes (and having passwords available to carry them out) is another sign of respect.

Handling death in all its forms is hard, but what does it say that we sometimes do a better job with our pets than with our parents? In My Cat’s Death, a Human Comfort “Recently, when I told a friend about my cat’s death from cancer, I found myself saying, “It was such a better experience than when my mom died!” I realized how crazy it sounded — I hadn’t meant to compare their deaths like accommodations on Trip Advisor — but it was true.”

Etc.
OK, if anyone is still with me, we’re almost done for this week.

A long overdue emphasis on EHR interoperability is finally here: Federal health IT coordinator sets 2017 deadline for interoperability “The federal health IT coordinator released a wide-ranging report Friday morning on how to improve interoperability in electronic health record systems. The report, “Connecting Health and Care for the Nation, A Shared Nationwide Interoperability Roadmap,” calls for most providers to be able to use their systems to send, receive and use “a common set of electronic clinical information. . . at the nationwide level by the end of 2017.””

Continued back and forth regarding how to regulate new healthcare technology: This Medical Supercomputer Isn’t a Pacemaker, IBM Tells Congress, but some in Congress aren’t listening: Dems balk on medical technology bill

And finally, from someone who has experienced both, a comparison of the US and British healthcare systems: What It's Like When You're An American Using Britain's NHS.


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"

Monday, January 26, 2015

HHS announces they are going for Better, Smarter, Healthier

Today (1/26/15) HHS made a historic” announcement regarding how Medicare will change the way it pays for medical care:

“…Health and Human Services Secretary Sylvia M. Burwell today announced measurable goals and a timeline to move the Medicare program, and the health care system at large, toward paying providers based on the quality, rather than the quantity of care they give patients.” (Better, Smarter, Healthier: In historic announcement, HHS sets clear goals and timeline for shifting Medicare reimbursements from volume to value)

The announcement sets out admirable goals and is gutsy in that it lays out specific benchmark numbers by which success can be judged.  But as is to be expected with any announcement of this scope, there are elements to be admired and elements to be questioned.  Below is an initial review of the announcement and some of the coverage.

The Secretary’s blog post on the changes included this regarding the need for change:

“Whether you happen to be a patient, a provider, a business, a health plan or a taxpayer, it’s in our common interest to build a health care delivery system that’s better, smarter and healthier – a system that delivers better care; a system that spends health care dollars more wisely; and a system that makes our communities healthier.” (Progress Towards Achieving Better Care, Smarter Spending, Healthier People)

There is also a piece by the Secretary in the New England Journal of Medicine

 “The Department of Health and Human Services (HHS) now intends to focus its energies on augmenting reform in three important and interdependent ways: using incentives to motivate higher-value care, by increasingly tying payment to value through alternative payment models; changing the way care is delivered through greater teamwork and integration, more effective coordination of providers across settings, and greater attention by providers to population health; and harnessing the power of information to improve care for patients.”
“Although we have much to celebrate regarding increased access and quality and reduced cost growth, much of the hard work of improving our health care system lies ahead of us.” (Setting Value-Based Payment Goals — HHS Efforts to Improve U.S. Health Care)

Concurrently, the following fact sheets were released:


To read a fact sheet about the goals and Learning and Action Network: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26-3.html

To learn more about Better Care, Smarter Spending, and Healthier People: http://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-01-26.html

As might be expected, there was immediate coverage of the news:

This piece reviews the announcement and what it is trying to accomplish: Obamacare 2.0: the White House's radical new plan to change how doctors get paid

“If this works, the White House hopes it will do two things. The first is improve the quality of health care in the United States, by paying doctors the most when they provide the best care possible. Second, and perhaps more importantly, the Obama administration sees this new plan as a way to cut health care spending by dis-incentivizing unnecessary medicine. Wasteful care is a huge problem in the United States: the Institute of Medicine estimates we spend $210 billion annually on medicine that doesn't make us any healthier.”

“Medicare has been experimenting with payment models for more than a decade, and the 2010 Affordable Care Act tackled the issue by expanding payment models that reward providers for the value of care they provide. The programs include lump sum payments for treating a patient throughout an episode of care, like a knee replacement surgery. The most high-profile effort has been with accountable care organizations (ACOs), which are groups of providers who share in the savings – or losses – for managing patients on a budget.”

This piece reminds us that the methods of achieving the goals are still works in progress: The Obama administration wants to dramatically change how doctors are paid

“We still know very little about how best to design and implement [value-based payment] programs to achieve stated goals and what constitutes a successful program," concluded a 2014 Rand Corporation study funded by HHS. The report, which reviewed pay-for-performance models implemented over the past decade, said improvements were "typically modest" and often hard to evaluate.”

Given the Rand study, a certain degree of skepticism is to be expected (and is healthy when reviewing announcements of this nature): I’m hoping this isn't the Underpants Gnomes method of payment reform

And finally, this second piece, while calling it: A Courageous First Step includes a cautionary note about moving forward:

“Many have dipped a timid toe, or hedged their bets with low-regret moves like buying up practices and forming organizations that are Accountable Care Organizations (ACOs) in name only.”

“Unfortunately, this strategy is already too widespread, and likely to grow as long as large organizations are allowed to continue in “one-sided” (upside only) shared savings models, as recently proposed by CMS. It’s also a major reason why so few hospital-sponsored ACOs have actually achieved savings bonuses. Defensive moves by hospital systems provide a veneer of action, while consolidating regulator-blessed market dominance that can raise local prices without improving quality at all.”

My bottom line, this is a great step forward, but we need to remember that the changes in the way providers are compensated are still being refined.  In the end the system may need even more radical changes than those discussed today to achieve the stated goals.




Friday, January 23, 2015

That Was The Week That Was - Issue 45

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

This week’s newsletter is brought to you by the letter S and the letter M. From S we get the State of the Union and SCOTUS. From M we get Medicaid and Measles. All that, enrollment data, and much more.

State of the Union
If you blinked during the President’s speech, you may have missed the few words he had to say about health care. In fact, the words "Affordable Care Act" never crossed his lips. While I understand he had a lot to cover, a few select words about open-enrollment would have been helpful.

I wasn't the only one who noticed, Vox reported on the 6 big topics left out of the State of the Union and number one was: “Obamacare: The Affordable Care Act — Obama's defining policy accomplishment — was never mentioned by name during the speech. Nor did Obama mention that people can currently sign up for insurance under the law (open enrollment runs until February 15). There were a couple oblique references to the falling uninsured rate and the health cost slowdown, and to a new "Precision Medicine Initiative to bring us closer to curing diseases like cancer and diabetes," but that was it.””

The President did discuss a new initiative, Precision Medicine: “In short, it's one of the most promising and exciting fields of medical research. Precision medicine, also known as "personalized medicine," is about the knowledge we've gained by sequencing the human genome. It's the effort to turn that knowledge into better, more effective medicines.”  (What Obama's Plan for 'Precision Medicine' Really Means). An important and exciting topic, we’ll be looking forward to more specifics (although it’s been noted how few programs mentioned during State of the Union speeches end up making it into law).

Finally, the President promised to defend the law, reinforcing his theme of economic security with respect to healthcare "We can't put the security of families at risk by taking away their health insurance, or unraveling the new rules on Wall Street, or refighting past battles on immigration when we've got a system to fix," Obama said, speaking before a packed audience in the House chamber at the Capitol. "And if a bill comes to my desk that tries to do any of these things, it will earn my veto." (Obama: ACA is key to economic recovery)

ACA: Court Cases
 “The U.S. Supreme Court heard arguments Tuesday in a case that could block hospitals, doctors — or anyone else — from suing states over inadequate payment rates for providers who participate in the Medicaid program for low-income Americans.” (High Court Considers If Providers Can Sue States For Higher Medicaid Pay).

These suits have been used for years to force states to adjust their rates. It’s unclear where the Court will end up on this one: “Some U.S. Supreme Court justices are skeptical, based on questions they posed Tuesday, that healthcare providers should be allowed to sue state Medicaid agencies over low reimbursement rates. Other justices, though, asked where providers can challenge rates if not in court.” (Justices appear split on lawsuits over low Medicaid rates).

Lots more talk and theorizing regarding the subsidy case that will be heard in March. The Washington Post points out that For SCOTUS Chief Justice John Roberts, anti-Obamacare lawsuit poses major dilemma.

Nicholas Bagley finds Another strike against the plaintiffs’ case in King. And the question is asked Did Paul Ryan Undermine The SCOTUS Case To Topple Obamacare? Based on comments he made during a hearing in 2010 while the law was being debated. Expect lots more theories as we get closer to the hearing date.

Also this week, the Urban Institute took a look at The People Most at Risk of Losing Insurance in the Supreme Court’s Health Ruling and found “The people who could lose their health insurance as a result of a Supreme Court decision this year are predominantly white, Southern, employed and middle-aged, according to an Urban Institute analysis.” Primary Source: Characteristics of Those Affected by a Supreme Court Finding for the Plaintiff in King v. Burwell

ACA: Opposition
With Congress getting into the swing of things, opposition to the law is a popular topic. Once again, the GOP vows to repeal and replace ObamaCare (still no word on what replace is, but why should they change now). Specifically, the New Senate bill would overturn Obamacare's individual mandate.

The Senate also held a hearing on the bill to change the definition of full-time worker, although that didn’t go so well: Failure to Launch: Republicans returned to their war on Obamacare on Thursday. It didn’t go well. “At one point halfway through the hearing, Alexander and Collins were the only Republicans in the room, while nearly all the Democratic chairs were full. By the end, it was hard to miss which side thought it had come out on top. “This,” said Murray, the committee’s top Democrat, “was a very good hearing.””

Some perspective on the topic from Robert Reich, former Clinton Labor Secretary and UC Berkeley professor Robert Reich on Redefining Full-Time Work, Obamacare, and Employer Benefits.

Questions of strategy continued to divide the opposition: Plan to Use Budget Process on Health Care Law Divides GOP. And there was more activity on the state level: War Over Obamacare Heats Up In States.

ACA: Affordability/Premiums
A Gallup survey out this week found “Healthcare costs and lack of money or low wages rank as the most important financial problems facing American families, each mentioned by 14% of U.S. adults.” (Americans See Healthcare, Low Wages as Top Financial Problems). The percent siting healthcare costs has been fairly stable over time. Reminding us that while progress has been made in addressing issues of affordability for some, more work remains.

Another study stressing that point showed that one’s health can have financial ramifications past the cost of care: “Middle-aged adults with chronic conditions that got worse as they grew older are nearly twice as likely to default on their mortgages and 2.6 times as likely to lapse into foreclosure than those whose chronic conditions remained stable, according to a recent study that tracked people as they hit their 40th and 50th birthdays during the foreclosure crisis.” (Can getting sick push you into foreclosure?)

Also this week, two looks at premiums. The first by the NY Times uses Colorado as a case study for the variability in premium rates, reminding us that the market has not yet settled down from the initial disruptions caused by the laws changes: In Colorado, Disparity in Health Plan Prices Underscores Ambitions, and Limits, of Affordable Care Act.

Second, from the Commonwealth Fund a look at premium rate increase over 10% (that had to be filed with the Feds as a result of the law): What's Behind Health Insurance Rate Increases? An Examination of What Insurers Reported to the Federal Government in 2013–2014 “The Affordable Care Act requires health insurers to justify rate increases that are percent or more for nongrandfathered plans in the individual and small-group markets. Analyzing these filings for renewals taking effect from mid-2013 through mid-2014, this brief finds that the average rate increase submitted for review was 13 percent. Insurers attributed the great bulk of these larger rate increases to routine factors such as trends in medical costs. Most insurers did not attribute any portion of these medical cost trends to factors related to the Affordable Care Act. The ACA-related factors mentioned most often were nonmedical: the new federal taxes on insurers, and the fee for the transitional reinsurance program. On average, insurers that quantified any ACA impact attributed about a third of their larger rate increases to these new ACA assessments.”

ACA: Enrollment
This week’s enrollment report reflected a slight surge as it included the deadline (1/15) for coverage effective 2/1. For the week of 1/10-1/16 nationally plan selections were 400,253. This compares to 163,000 the previous week. It also looks like we'll get state figures every week now. The new cumulative number for Maine is 61,964 compared to 59,126 the previous week, meaning last week there were 2,838 plan selections in Maine last week. (Primary Source: Open Enrollment Week 9: January 10, 2015 – January 16, 2015)

The national totals reflect that the Government Closer to Goal of 9.1M Enrolled Under Health Law. Including state Marketplace numbers, ACASignups.net shows that At least 33 States have reached HHS Goal for 2015 with 25 days to go (w/bar-charty goodness!).

Kaiser created a chart showing Marketplace Enrollment as a Share of the Potential Marketplace Population. This shows that in Maine plan selections were 61,964 compared to the estimated potential enrollees of 124,000, yielding a percent reached of 50% - one of the highest in the nation.

We'll expect another larger surge next month as we near the end of this year’s open-enrollment on 2/15. As we approach the deadline, some enrollment efforts have shifted to stress the mandate penalties more so than in the past (start with the carrot, end with the stick): Mandate figures in final stretch of Obamacare messaging.

ACA: Marketplaces
The Office of the Inspector General issued its report on the initial rollout of healthcare.gov and it pulls no punches. The report confirms what we already knew, that the planning and oversight was terrible: Federal Marketplace: Inadequacies in Contract Planning and Procurement.

here were also New Privacy Concerns Over Government's Health Care Website. To be clear, everything going on complies with accepted standards, no one’s personal information is allowed to be used by outside firms. That said, the article talks about what-if scenarios if vendors were to violate their contracts and asks reasonable questions as to if all the current processes are needed.

Looking forward, the President of Enroll America has some thoughts on changes that should be made for the next open enrollment period: The Future of Enrollment: Modest Policy Changes in Year Three Will Go a Long Way.

A new study finds an area ripe for improvement is the descriptions of prescription drug coverage: Obamacare Drug Coverage Descriptions May Confuse Consumers About Costs, Study Finds “Square peg, round hole. More than a third of silver plans offered on the federal health insurance marketplace may be listing inaccurate or incomplete prescription drug cost-sharing information because their formularies don’t fit neatly into the federal government’s online template, a recent analysis found.”

ACA: Other
This week in Washington consumer advocates are meeting at Families USA’s annual conference. In advance of the conference, Families released a new brief: Health Reform 2.0: A Call to Action “Both a call to action and a roadmap for progress, Families USA’s latest report, Health Reform 2.0 lays out a path for securing high-quality, affordable health care to all Americans—regardless of income, age, race, or ethnicity—and for achieving the “Triple Aim”: improving health, enhancing quality of care, and reducing health care costs.” Noble goals all, but brief lacks a realistic discussion of what progress is possible given the current political environment.

While I worry about progress on the Federal level, some states are able to move forward as California Takes Different Path On Insuring Immigrants Living In U.S. Illegally. Remember, the ACA specifically prevents any of its benefits or federal money being used to provide services for the undocumented. CA is trying to address this gap with state dollars.

And now, this week’s edition of bad headlines (and reporting): ER visits still rising despite ACA: The statistics the article talks about are from 2013, before most of the ACA took effect. Then the story includes anecdotal evidence from 2014, predominantly from states that have not expanded Medicaid. The story also quotes the spokesman for the American College of Emergency Physicians who has been opposed to the law since the beginning without providing context or alternative interpretations. Yet another reminder that just because you read something, doesn’t mean it’s true. (A lesson you should all be applying to what I write as well!)

Measles
Lots more news this week about the Disneyland measles outbreak as the number of confirmed cases climbed to 67 (67 confirmed cases of measles in California-centered outbreak).

First the sad irony that Ebola Was Just A Warm-Up: The Measles Outbreak Is For Real. “Contrasted against the public’s approach to Ebola, the ironies are manifold. We ignored Ebola, until it came to America — then we panicked. Our measles problem is entirely self-created, yet we’re not panicking enough. Ebola tore through West Africa, because those nations are stuck with vulnerable health care systems; America’s wealthiest communities are vulnerable to measles, because of misguided choices.”

Here is an excellent review of the issues: Five Things To Know About The Disneyland Measles Outbreak.

If you click on one link in this section, here it is: The devastating impact of vaccine deniers, in one measles chart. We had conquered measles in this country, until we started going backwards.

Vaccine deniers tend to live near each other, which only serves to increase the risk to all: Parents Who Shun Vaccines Tend To Cluster, Boosting Children's Risk.

But there may be a ray of hope. Things are slowly improving in CA where “A state law that went into effect last year made it more difficult for parents to excuse kindergartners from vaccines. Instead of signing a form, parents now must get a signature from a healthcare provider saying that they have been counseled on the risks of rejecting vaccinations.” (Fewer California parents refuse to vaccinate children) A similar law is being introduced here in Maine in the current legislative session, we can only hope that it will pass quickly!

Finally, both to lighten the mood and in honor of the impending return of House of Cards (2/27) here is an oldie but a goodie, Dr. House of Cards dealing with an anti-vax mom.

Medicaid
Lots to talk about on the Medicaid front this week. Starting off, CHIP funding was back in the news. First a reminder that Millions of children could soon lose their health insurance if Congress doesn’t act. Then some potentially encouraging news from Senator Hatch: “On CHIP, Hatch said the Finance Committee has “heard from a number of governors from red states and blue stakes alike that they want to see this program extended. It has been a marvelous program. It has worked very, very well. I’m optimistic that we can work on a bipartisan, bicameral basis to extend CHIP in a responsible way.”” (Hatch Vows To Dismantle Health Law But Predicts Bipartisan Success On Other Issues).

Out this week was a study in the New England Journal of Medicine showing increased PCP rates led to improved availability of providers: Appointment Availability after Increases in Medicaid Payments for Primary Care “Our study provides early evidence that increased Medicaid reimbursement to primary care providers, as mandated in the ACA, was associated with improved appointment availability for Medicaid enrollees among participating providers without generating longer waiting times.” This as those rates reverted in most states back to their previous levels. You can see each state’s decision here: Medicaid PCP Fee Map. An in-depth discussion of the topic can be found here: Study: The doctor is more likely to see you now - NEJM study reaffirms what even Red state governments realize: patients do better in states with higher Medicaid reimbursement rates

Also out this week from Kaiser “This 13th annual 50-state survey of Medicaid and CHIP eligibility, enrollment, renewal, and cost-sharing policies as of January 2015 provides a snapshot of state Medicaid and CHIP policies in place one year into the post-ACA era.” (Modern Era Medicaid: Findings from a 50-State Survey of Eligibility, Enrollment, Renewal, and Cost-Sharing Policies in Medicaid and CHIP as of January 2015)

While the administration has been flexible in allowing red states to put their own “spin” on Medicaid expansion through plan designs like the private option, those changes seem to have more to do with dogma than with effectiveness or efficiency: Red States Are Reinventing Medicaid to Make It More Expensive and Bureaucratic “The Republicanized versions of Medicaid thus far have ended up more complicated, confusing, and possibly costlier than the program Republicans refused to expand in the first place.”

And speaking of the private option, back in Arkansas, the state that paved tried it first, finally word from the newly elected Governor that he would in fact support continuing the program: New Arkansas governor wants to renew, then rethink, Medicaid expansion  “Arkansas Republican Gov. Asa Hutchinson called on the Legislature to keep through 2016 the state’s private-option approach to Medicaid expansion, backed by his Democratic predecessor, so that roughly 200,000 low-income residents won’t lose access to insurance coverage.” But he still has to get the plan through his state legislature, which is far from a sure thing.

Meanwhile, for those who thought the impossible might be possible, no such luck. You can take TX off the list of possible expansion states: “Democrats and health care advocates had hoped that Mr. Abbott would reverse Mr. Perry’s refusal to expand Medicaid in the state, which has the highest rate of uninsured residents in the country. But Mr. Abbott made it clear recently that he would not expand the government health insurance program for low-income and sick people, with a spokeswoman saying that he had “fought Obamacare and will continue to fight against it.””  (Texas’ New Governor Echoes the Plans of Perry).

Medicare
A new health policy brief out this week on The Two-Midnight Rule “Hospitals can provide services on either an inpatient or an outpatient basis. Medicare pays for inpatient services and outpatient services under separate and very different payment systems, which can produce substantially different payment amounts for similar patients receiving similar services. The cost-sharing implications for beneficiaries under the two systems can also vary significantly.”

With Congress back in session, “Doc Fix” season has begun as the perennial discussions get started: Predictable fault lines emerge as perennial doc-fix debate begins.

Costs
Have you ever asked yourself what’s the difference between an ACO and an HMO?  No? Go ahead, I’ll wait. Ready?  OK, here’s the answer to your questions: Accountable Care Organizations: Like H.M.O.s, but Different.

We alluded to this last week in the discussion that hospitals were being rewarded on some programs and penalized on others, here’s a more detailed look at the issue: 1,700 Hospitals Win Quality Bonuses From Medicare, But Most Will Never Collect “Medicare is giving bonuses to a majority of hospitals that it graded on quality, but many of those rewards will be wiped out by penalties the government has issued for other shortcomings, federal data show.”

Also on the cost front, a nice column by Christy Daggett of MECEP on progress in price transparency, and its limitations: Colonoscopies for $3,166 or $721: Why finding out is progress

Drugs
Attention called to an ongoing risk of birth defects as “The federal health authorities reported Thursday that nearly one-third of women of reproductive age had had an opioid painkiller prescription filled every year from 2008 to 2012. Experts said the practice carried considerable risks for birth defects.” (High Rates of Opioid Prescriptions Among Women Raise Birth Defect Fears).

Here in Maine, attention was focused on a potential change in Medicaid reimbursement policies: Thousands of patients lose if state cuts methadone benefit: DHHS claims Suboxone is a better treatment, but health experts disagree and question whether the state is practicing medicine.  Unfortunately, another example of public policy being shaped by dogma, not by scientific evidence.

Also in Maine, continued confusion over the state’s first in the country law to allow importation of prescription drugs: Bangor man caught in conflict between Maine mail-order pharmacy laws, federal government. It seems like this may be an isolated glitch in the process, not an attempt to prevent the practice – but it needs watching.

Back on the national front: This Giant Drug Firm Won't Invent Medicines. Investors Are Cheering. Yes, you read that right, this firm no longer wants to do any research…

And speaking of research, Senator Wants Big Drug Makers That Break the Law to Fund NIH “Seeking to replenish funding for new scientific research, U.S. Sen. Elizabeth Warren (D-Ma.) plans to introduce a bill next week that would require drug makers that break the law to send some of their profits to the U.S. National Institutes of Health.”

System Transformation
A Kaiser issue brief discusses Tapping Nurse Practitioners to Meet Rising Demand for Primary Care “Over 58 million Americans reside in geographic areas or belong to population groups that are considered primary care shortage areas…  The demand for primary care is projected to rise over the next five years, due largely to population growth and aging, and to a smaller extent, to expanded health insurance… However, a recent Institute of Medicine (IOM) report on shaping the health care workforce for the future noted that such projections of primary care physician shortages are generally based on traditional health care delivery models and do not consider the potential of an expanded primary care role for physician assistants and advanced-practice nurses, redesign of health care, telehealth, and other innovations. This brief focuses on the untapped potential of one type of advanced-practice nurses – nurse practitioners – to increase access to primary care.”

At the same time, statistics show that the number of Nurse practitioners doubled in 10 years. The healthcare workforce of the future will look very different than it does now. Another example: MDs and CRNAs: Highlighting each other’s expertise Hope that a new generation of providers will help end the turf wars.

Part of the new approach involves teams. Working in teams holds the promise of practitioners being able to devote the appropriate time to their patients. Several developments this week highlight the need for changes:

First a study showing that Docs make fewer diagnostic mistakes in teams, study finds “Those working in pairs took 2:02 minutes longer than individuals, but they were also more accurate in selecting a diagnosis (68 %) compared with those working individually (50%). Overall, pairs expressed more confidence in their decision than those working alone.”

Second, a look at what happens in our current system when things are rushed: Physicians blame patient 'treadmill' for missed calls. This piece provides an in-depth look at the misdiagnosis subset of medical errors.

When errors are made, how should they be handled?  This Mass. Malpractice Reforms Offer Faster, More Open Process For Injured Patients. An important conflict resolution program that could serve as a national model.

Being open and transparent with patients has incredible potential, highlighted in a new report from the National Patient Safety Foundation: Shining a Light: Safer Health Care Through Transparency ”During the course of health care’s patient safety and quality movements, the impact of transparency—the free, uninhibited flow of information that is open to the scrutiny of others—has been far more positive than many had anticipated, and the harms of transparency have been far fewer than many had feared. Yet important obstacles to transparency remain, ranging from concerns that individuals and organizations will be treated unfairly after being transparent, to more practical matters related to identifying appropriate measures on which to be transparent and creating an infrastructure for reporting and disseminating the lessons learned from others’ data.”

Another change needed is making better use of technology to improve patient care. “The project aims to advance cancer care by providing clinicians instant feedback through clinical decision-making tools, the ability to uncover previously unseen patterns in patient treatment and outcomes, and offer more personalized insights into a patient's disease, ASCO leaders said.” (ASCO readies big-data cancer quality initiative)

Highlighting some work here in Maine, first a piece from Dr. Mills discussing the lessons of the Franklin County work discussed last week: “And we now have the research to show that these multi-sector, communitywide prevention interventions combined with access to integrated health care are associated with significantly improved health and reduced health care costs.” (How Maine’s Franklin County proved health care shouldn’t be provided in a bubble)

Second a look at how Maine treatment for mental illness serves as national model “On hiatus but soon to be restarted, a program that began at Maine Medical Center has led the way toward early detection and treatment of schizophrenia.”

An important (if sad) reminder that Cough and cold medicines for kids are likely a waste of your money and an unnecessary risk “As pediatricians, we really wish that we could recommend something to help parents and children feel better. Unfortunately, over-the-counter cough and cold medicines are not the answer. First of all, they don’t work.”

And finally, under the heading of who would have guessed this 20 years ago: Twitter Can Predict Rates of Coronary Heart Disease, According to Penn Research “The Penn researchers demonstrated that Twitter can capture more information about heart disease risk than many traditional factors combined, as it also characterizes the psychological atmosphere of a community.” …  ““Twitter seems to capture a lot of the same information that you get from health and demographic indicators,” Park said, “but it also adds something extra. So predictions from Twitter can actually be more accurate than using a set of traditional variables.””


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"