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"
