This is it, the final issue of “That Was The Week That
Was”. I've been thinking a lot about
what I want to say, I thought about last lines of novels, movie quotes and
more. But in the end, it’s very simple,
what I want to say is thank you. Thank
you for reading, thank you for sharing this time with me, and most of all thank
you for caring enough about health care (both your own and everyone else’s) to
take the time to think about these things.
While I’m saying thanks, a big thank you to the Maine Health
Access Foundation for making this all possible by supporting this newsletter
for the past year.
Remember, I'm not dying…
While I won't be producing this weekly newsletter, I expect I'll
continue to have something to say on the topic of health care and will post
occasional blogs. I've added an email
notification function to this blog if you're interested in keeping up. For those
who are curious, no news yet on what comes next for me so stay tuned.
To help you keep up with health policy news going forward,
I've put together this guide to the email subscriptions, websites and twitter
feeds I use: How
to be a health policy wonk.
And now, for the last time:
This week we take a look at; more King v. Burwell news,
detailed enrollment numbers, affordability issues, CBO cost estimates and more.
So let’s get started.
ACA: Court Cases
Still thinking about the case? If you want to feel like you were there, the
audio recording of oral arguments have now been released: Audio file
of King v. Burwell oral arguments.
Did you know there is a fantasy SCOTUS league? Of course there is. We know that often the “hive mind” is smarter
than any one pundit. So in the tradition
of “ask the audience”
take a look and get a sense of what people think will happen: Fantasy
SCOTUS - King v Burwell.
The NY Times took a detailed look at the potential human
cost of a decision for the plaintiffs: A
Roadmap for How Many People Could Lose Their Health Insurance “So how many
people in how many states could be affected by the big Supreme Court case about
Obamacare’s insurance subsidies? Good question. A combination of data problems
and legal ambiguities make some basic facts about the case difficult to
summarize easily. Last week, news media coverage included widely ranging
numbers of people who could lose their insurance and where they live. Here’s
why it’s hard to estimate.”
Then of course there is the political fallout. What happens when the dog catches the car? GOP
braces for ObamaCare win “While top Republicans in the House and Senate
said this week that they are nearing a consensus on their efforts to create a
back-up plan for the subsidies, almost no details have been shared about the
half-dozen plans unveiled in the last two weeks. Most of the proposals are
drawing criticism from their fellow conservatives behind the scenes. “It’s a
couple lines in an op-ed. Who knows what it really means? In some of those,
they may not know, frankly,” said one conservative strategist and former Hill
healthcare staffer. Creating even a temporary solution for ObamaCare subsidies
is a huge dilemma for the GOP-controlled Congress. Some Republicans have even
said, albeit quietly, that the party could be better off if the
administration’s policy survives the Supreme Court challenge.”
What about on the state level? No clear answers there either as GOP
governors scramble for answers on ObamaCare ““The Republicans potentially
have a PR nightmare on their hands, because what’s going to happen when 8
million people are going to be denied subsidies?” said Ford O’Connell, a
Republican strategist and member of The Hill’s Contributors Blog. The fight
over King v. Burwell is further complicated by the fact that several GOP
governors could be launching presidential campaigns near the time the court
reveals its decision, expected in June.”
Some states are trying to figure out their options: Health-Law
Ruling Could Prompt Some States to Act “Nevada is one of three states that
use HealthCare.gov for most day-to-day operations after their own exchanges ran
into technical problems. It says it believes its residents would be able to
keep tax credits—and that other states could do what it has done. Bruce
Gilbert, the head of the Nevada insurance exchange, said he has talked with the
federal government and states, including Delaware and Maine, about that
possibility. A Delaware official said the state was reviewing all its options.
Maine officials didn’t immediately comment.”
Presidential candidate Jeb Bush talked about his
alternative. He seems to be worried about the wrong problem: Jeb
Bush: Replace 'Monstrosity' Of Obamacare “Bush's criticism of Obamacare as
"the greatest job suppressor in the so-called recovery" is
interesting, given that the country is experiencing the greatest period of job
growth in two decades. On Friday, the Labor Department announced that the
economy gained 295,000 more jobs in February, ticking the unemployment rate
down to 5.5 percent.”
And in trying to solve a non-existent problem, he seems
intent on making things worse: Jeb
Bush's consumer-choice model offers questionable choices ““Republicans are
really saying that people should be free to avoid carrying insurance for
problems they don't expect to have (a bout of depression, maybe, or a stroke
that requires rehabilitation) or don't want to help pay for (pediatric and
maternity care for men with no children, say). The former view shifts costs
onto the unlucky; the latter shifts costs onto women and parents. Both undercut
the purpose of insurance, which is pooling risk. Neither saves money. Yet in
the abstract the argument sounds compelling. And it's going mostly
unchallenged.””
Believe it or not, the Supreme Court does handle other cases
than King v. Burwell. This week they told
a lower court to take another look at one of the contraceptive cases: Supreme
Court orders another look at birth control coverage case “The U.S. Supreme
Court on Monday took action in a case over how religious not-for-profit employers
must meet the Affordable Care Act requirement to cover birth control for
employees—a move some say could be significant for those employers. Others, however, disagree, saying the action
changes nothing legally.”
For now, I choose to listen to Tim Jost who said: “I do not
believe too much should be read into the Supreme Court’s action. The most likely explanation of the Supreme
Court’s decision seems to be that several of the justices on the Court believe
that, with about fifty cases challenging the federal rules accommodating the
objections of religious organizations working their way up through the courts,
this issue is not going away, but the Notre Dame case was not yet ripe for
review; Notre Dame was decided not only before Hobby Lobby, but also before the
latest set of regulations attempting to accommodate the objections of religious
organizations, issued in August of 2014.
The Seventh Circuit, therefore, had not had occasion to consider both
developments.” (This link also discusses CBO cost estimates which I cover in
the Cost section below: Implementing
Health Reform: Supreme Court Remands Contraceptive Case; ACA Cost Estimates Go
Lower)
ACA: Enrollment
CMS released more detailed numbers from the just completed
open enrollment period: Nationwide
nearly 11.7 million consumers are enrolled in 2015 Health Insurance Marketplace
coverage “More than 4.1 million young people selected a plan or were
re-enrolled; nearly 7.7 million people with plan selections in HealthCare.gov
states qualify for an average tax credit of $263 per month”
Lots of interesting information in the report: 86
Percent of Health Law Enrollees Receive Subsidies, White House Says. You can find state specific results here: Health
Exchange Enrollment Climbs in Second Year. And
Jackie Farwell takes a look at Maine’s numbers here: Decoding
Maine’s Obamacare enrollment numbers.
Others dived into the report looking at enrollment by age: Exchange
enrollment sees limited progress with youth, minorities and income: Implementing
Health Reform: March Enrollment Report Provides Income Data. Also, more details on the results of reenrollment:
Obamacare
Enrollees Are Surprisingly Smart Shoppers.
ACA: Affordability
Like the author of this next piece, I often get asked why if
health care costs are going down, the man on the street is not seeing any
benefit. Here is (part of) the answer: Your
company's health insurance costs are going down. But yours are going up. “The
Center for American Progress published a new report this month that gives the
best answer I've seen to this question. It shows that no, the government isn't
lying about slower health-care costs — they really are going up slower than
they used to. But all those savings? They're not going to you, or me, or other
consumers. They're accruing to the rest of the health-care system.”
The Kaiser Family Foundation took a detailed look at
affordability from the perspective of cost sharing: Consumer
Assets and Patient Cost Sharing “Plans with higher deductibles and other
point of service costs provide health plan enrollees with incentives to make
more cost conscious health care choices. For families with limited resources,
however, high cost sharing can be a potential barrier to care and may lead
these families to significant financial difficulties. Many current policies
expose individual enrollees to thousands of dollars in cost sharing expenses
and family expenses can easily top ten thousand dollars when someone becomes
seriously ill.”
Vox boiled the report down to its essence: The
health insurance deductibles are too damn high, in one chart “A new Kaiser
Family Foundation study explores one big repercussion of that trend: lots of
American families wouldn't have enough cash on hand to cover the average
deductible.”
However, keep in mind that many of those enrolled through
the marketplace not only receive premium subsidies, they receive cost sharing
subsidies as well. The Tim Jost post
linked to in the enrollment section also takes a look at cost sharing subsidies
(Implementing
Health Reform: March Enrollment Report Provides Income Data). It’s not that I don’t think there is a problem, it’s
that like everything else in healthcare, there are nuances to the situation that
need to be taken into account.
Another truism about healthcare is that specific issues can
make for strange bedfellows. Pharmaceutical
firms are teaming up with consumer groups to help pass state laws limiting
copays. While short term that can be
good news for consumers, that’s not why the pharmaceutical firms are doing it. Long
term these laws do nothing to stem the high cost of drugs – it just means we
pay for it in premium dollars instead of in cost-sharing: “Such
patient-assistance programs, which often are funded largely by drugmakers, have
helped many Americans like Rucker afford the medications they need. But these
programs' ties to pharmaceutical companies carry a high cost for the healthcare
system, critics say. It's an issue with growing resonance as drug prices
continue to climb. Prescription drug spending grew 13% in 2014, compared with
5.6% growth of healthcare spending overall, according to a recent Altarum
Institute report.” (Lifesavers
or kickbacks? Critics say patient-assistance programs help keep drug prices
high)
In other affordability news, progress
from the credit agencies in how medical debt is treated: Credit
Rating Agencies Agree To Be More Flexible About Medical Debt “The
agencies say they will establish a 180-day waiting period before medical debt
is added to someone’s credit report. In addition, the agencies agreed that when
an insurer pays a bill, the debt will be promptly removed from the consumer’s
credit report, unlike certain debts that remain for years.”
ACA: Other
Regulations are one thing, compliance is another: “A new
study by the Johns Hopkins Bloomberg School of Public Health found that
consumer information on a quarter of the Obamacare plans that researchers
examined appeared to go against a federal "parity" law designed to
stop discrimination in coverage for people with mental health or addiction
problems.” (Mental
health coverage unequal in many Obamacare plans)
ACA: CBO Estimates
The Congressional Budget Office released new budget
projections, including projections of what the ACA will cost going forward. The numbers can only be described as
remarkable: “The budget office has repeatedly lowered its estimate of the cost
of the health care law since the bill was signed by President Obama in March
2010. At that time, the budget office said that the law’s insurance-related
provisions would cost the federal government $710 billion from 2015 through
2019, the last year of the 10-year projection period used then. On Monday,
Douglas W. Elmendorf, the director of the Congressional Budget Office, said the
new projections indicated that “the cost will be $506 billion for that same
period, a reduction of 29 percent.” (Budget
Office Again Reduces Its Estimate on Cost of the Affordable Care Act)
It has been endlessly debated as to if the current cost
slowdown is the result of the recession or other systemic forces at work. Regular readers know that I think it’s
both. Apparently the CBO agrees with me:
“Behind these numbers is the sharp slowdown in health-care spending growth. The
reduction "is largely a result of projections of slower growth in premiums
and, to a lesser extent, slightly lower exchange enrollment," CBO analysts
write. Some of that is likely the result of the recession — when people have
less money, they tend to have less to spend on medical care. But what the CBO
is saying in this report is it thinks the slowdown will have an effect that
stretches out over the next decade and way past the recession.” (CBO:
Obamacare subsidies will cost 20 percent less than expected)
Costs
While we've had some good news the past few years regarding
cost, the battle is far from over.
Accountable Care Organizations (ACOs) are one of the ways
people are trying to hold down costs while still improving quality. This week an optimistic look from the
Commonwealth Fund at how some of those experiments are going: A
Unicorn Realized? Promising Medicaid ACO Programs Really Exist “Some people
used to say that accountable care organizations (ACOs) are like unicorns—they
sound amazing but nobody has seen one in real life. However, with hundreds of
ACOs now sprouting up in an array of shapes and sizes in Medicare, Medicaid,
and the commercial sector, this saying has finally been put to rest. Still,
until recently, it’s been unclear whether ACOs can live up to the hype or are
just a passing health care reform fad. Although the results are preliminary,
the experiences of Medicaid ACO programs in Colorado, Minnesota, and Oregon
show that this model of coordinating care—and then sharing in the resulting
savings with payers—holds real promise.”
Also on the ACO front, CMS released details about their “next
generation” ACO model. To be honest, I
have remained skeptical that ACOs can achieve everything promised (see unicorn
label above). That said, it looks like
these new guidelines represent an improvement over current models: CMS
preps 'next generation' ACO model “In a significant departure from
Medicare's existing ACO programs—the Shared Savings Program and the Innovation
Center's Pioneer model—patients will be able to voluntarily enroll in
accountable care and in exchange, have their co-pays reduced or eliminated for
some services, such as primary-care visits, Conway said.” Primary Sources:
Press Release - Affordable Care
Act initiative builds on success of ACOs and CMS resource page - Next
Generation ACO Model
Of course payment reforms continues forward on many fronts. On the benefit design side, reference pricing
is all the rage. Two pieces in Health
Affairs sounds a note of caution on the concept:
Go
Slow On Reference Pricing: Not Ready For Prime Time “Reference pricing is
superficially appealing because it invokes powers that consumers exercise every
day, as they weigh cost and value for items ranging from cold cereal to new
cars. But it also raises significant issues regarding quality and access to
care and has the potential to discriminate against sick and vulnerable
patients. The strategy may also prove costly in relation to the benefits it
confers. We urge a go-slow approach and more careful regulation.”
Go
Slow On Reference Pricing: Why The Federal Agencies Have It Wrong On
Regulations “Network adequacy rules involve a delicate balance of ensuring
access while protecting affordability. Plans have limited tools to obtain lower
prices, and exclusion from networks can help control expenditures. By contrast,
reference pricing promises little savings, and so regulation and policy should
focus on ensuring access and avoiding the problems we’ve enumerated.”
With all the changes in payments and benefits, we’ve seen an
acceleration in provider consolidation.
Some argue that the new systems will be able to provide better care at
lower cost, but others have questions: Consolidation
and health reform “There’s little disagreement that health care providers
are consolidating. I do not detect a similar degree of agreement about the
consequences. Hospitals and other providers tend to justify consolidation on
the grounds that it will improve quality and reduce costs. For years, health
policy experts viewed such claims skeptically.”
Medicaid
Every week there is another state talking about Medicaid
Expansion (not actually expanding, but at least talking about it). This week was no different: “None have an
easy path, but at least they’re talking: “Kansas, Utah, and Montana all took
steps towards the coverage expansion this week, a move that could expand
health-care coverage to 297,000 of their low-income residents. They're among
the 22 states that have not expanded their Medicaid programs after the Supreme
Court made that part of the health law optional in 2012.” (The big
Obamacare news last week wasn't at the Supreme Court. It was in Kansas.)
The news out of Florida asked a different question, is the Administration
shifting its strategy when it comes to dealing with the states on this topic? Is
the Obama Administration Playing Hardball on Health Care? The current debate in
Florida over Medicaid funding could be a sign of things to come. “Florida
has more than $1 billion in federal Medicaid funding that will expire this
summer, and the Centers for Medicare and Medicaid Services has already said
that that funding, which helps compensate health care providers that serve a
lot of uninsured and low-income Floridians, won't be renewed as is. Legislators
are now rushing to take up Medicaid expansion this month.”
Medicare
The coming of Spring can only mean one thing – it’s “Doc Fix”
season! The annual game where Congress
finds a way to prevent the automatic cuts to Medicare reimbursement levels from
going through: Get
Excited, Everyone, It’s ‘Doc Fix’ Time “Doctors will see a cut of more than
20 percent in their Medicare payments unless Congress steps in by the end of
the month. Congress almost surely will step in—it always does. And it will
probably just delay the cut for another few months—as it always does.”
Although last year they seemed to get close to a permanent fix,
it fell apart in the end. Some hold out hope that this year will be different: Momentum
building in Congress for $174 billion Medicare fix “Momentum is building in
Congress for a proposal that would abolish Medicare cuts, top Republicans said
Thursday, despite the emerging battle over the $174 billion price tag. Optimism
has been growing this week that Congress could finally reach its long-sought
goal of ending the automatic cuts to doctors under Medicare, which come through
what is known as the Sustainable Growth Rate (SGR).”
Another sign of Spring, at least for the past few years,
has been the attempts to minimize the cuts to Medicare Advantage plans. A quick review, Medicare Advantage was
supposed to be a way for private insurance to provide Medicare benefits less
expensively than the government. Instead
over the years it grew to cost as much as 120% of standard
Medicare per enrollee. The ACA has provisions to
bring the private costs more in line with standard Medicare. However, the private insurance companies have
made a nice profit on their Medicare Advantage plans and don’t want to see
those changes go through. So, each year CMS announces new reimbursement levels
and Congress pressures them increase the proposed rates. This year’s episode is
just getting underway: Congress
Pleads for CMS to Stop Private Medicare Cuts “A group of 239 House members
is sending a letter, provided exclusively to National Journal, to the Centers
for Medicare and Medicaid Services on Thursday, urging the agency to reverse
the cuts to the private Medicare plans, which serve 16 million seniors, that
CMS proposed last month.”
Drugs
I love the First Amendment.
Freedom of speech is one of our most important rights. But like anything in the real world, it
should not be absolute. I don’t believe
you have the right to yell “fire” in a crowded theater when there is no fire. With
that in mind, I find this movement to stem the FDAs power disturbing: How
the First Amendment is undermining the FDA’s power to regulate drugs “The
Food and Drug Administration is proposing to allow pharmaceutical companies to
contradict official safety warnings in sales presentations to customers. … The
proposal “seriously undermines FDA authority,” Sidney M. Wolfe, founder of
Public Citizen’s Health Research Group wrote Wednesday to the agency. “Its main
supporters are drug companies and their associations, all of which would
benefit from being allowed and encouraged to sell more drugs by making them
seem safer than FDA has judged them to be.””
A report from Express Scripts shows that Drug
Costs Grew Last Year at Fastest Rate in Decade “Per-person spending by
commercial health plans jumped 13 percent, the most since 2003, as spending on
specialty drugs grew 31 percent. That includes cancer drugs, which rose 21
percent last year, and hepatitis C treatments, which rose more than eightfold,
pushed up by Gilead Sciences Inc.’s Sovaldi.”
An increase in drug costs is not in and of itself a bad
thing. Drugs hold the promise of
treating people and helping their conditions improve. If a new drug costs twice as much as an old
drug, but allows those taking it to live 10 more years, that’s probably a good
value.
That said, evidence that we are not getting significant improvements
in treatment for (at least some) of the extra spending: The
high price of precision medicine “Why are prices for specialty drugs rising
so quickly? In most cases, it's not because they offer significant improvements
over previous therapies. A new study in the Journal of Economic Perspectives,
which looked at the price and health benefits of 58 anti-cancer drugs approved
between 1995 and 2013, found “gains in survival time associated with recently
approved anti-cancer drugs are typically measured in months, not years.” What
has gone up significantly is the cost of each month of life gained through the
new treatments. The inflation-adjusted price for new anti-cancer drugs rose 10%
a year over those 18 years, according to the study. In 1995, patients and
insurers paid $54,100 (in 2013 dollars) for a year of extra life. By 2005, that
had gone up to $139,100 a year, and by 2013 it was $207,000.”
If the costs don’t get us, the antibiotic-resistant
superbugs will: 7
scary facts about antibiotic-resistant superbugs “Scientists and
public-health officials are a careful bunch who don't often use terms like
"nightmare," "apocalypse," and "catastrophe."
That is, until they're talking about the issue of antibiotic resistance. More
and more, as we learn that the threat of drug-resistant superbugs could literally
spell our end, it's become a worry akin to climate change: an overwhelming but
intangible menace that can be difficult to rally around.”
System Transformation
As a patient, there is nothing more important than
understanding our treatment options and their potential impact – but the sad
truth is we often don’t: The truth
about medicine: we usually overestimate the benefits and underestimate the
harms “Looking at 36 studies on a range of medical interventions — from
cancer screening tests to medications and surgeries — a pair of Australian
researchers discovered that, overwhelmingly, patients overestimated the
benefits and underestimated the harms.”
Here is a look back at the influence of “big sugar” on
government efforts to stem tooth decay.
Think what a difference it may have made to our current obesity problem
if in the 50s and 60s the government had moved forward with the recommendation to
eat less sugar: The
untold story of how the sugar industry shaped key government research about
your teeth “Despite a widespread understanding that sugar played a key role
in tooth decay, sugar industry leaders advocated for policies that did not
recommend people eat less sugar, according to an archive of industry letters
dating back to the 1950s preserved by the University of Illinois and analyzed
by a team of researchers at the University of California in San Francisco. And
the government listened, according to a new report.”
End of Life Care
Vox pulled together five excellent pieces on the topic (and
yes, my regular readers will have already encountered some of them in these
pages): 5
moving, beautiful essays about death and dying “It is never easy to
contemplate the end-of-life, whether its own our experience or that of a loved
one. This has made a recent swath of beautiful essays a surprise.”
As end of life care and decisions get more attention, there
is the need to bring our electronic health records into the picture: Non-interoperable
directives: End-of-life wishes and EHRs don't yet mesh “Advance directives
could be available to all caregivers through interoperable electronic
health-record systems. But for a majority of patients and providers, it's not
happening. Often, directives are not electronically accessible to emergency
physicians, emergency medical technicians, and nursing home or hospice staff
when they need them. Few EHR developers have templates in their systems to create, store and exchange end-of-life directives.”
The benefits of empathy training are not limited to end of
life care, but they would certainly help there as well: Efforts
To Instill Empathy Among Doctors Is Paying Dividends “Studies have linked
empathy to greater patient satisfaction, better outcomes, decreased physician
burnout and a lower risk of malpractice suits and errors.”
Homeopathy
An important meta-analysis out of Australia showing yet
again that Homeopathy is nonsense: Americans spend billions
on homeopathy. The best evidence says they're wasting their money. “What
may be the most exhaustive review yet of the evidence for homeopathy has come
to a very strong conclusion: the treatment doesn't work, and people should stop
wasting their time, money, and potentially their health on what amounts to junk
science.”
Apple Watch
Why am I talking about an Apple product announcement? Because there is potential for it to revolutionize
health care in two ways.
The first is the idea that it can help us accomplish some of
our goals such as remembering to stand up every hour – a great goal but some
remain skeptical the watch will fix the problems of our sedentary lifestyle: Stop
Bashing Apple Watch. It Could Change Health Care After All and Apple
is trying to launch a health revolution. Researchers are skeptical.
The second, perhaps even more revolutionary element, is by
providing a new way for health researchers to engage study participants: Apple's
ResearchKit draws massive interest (and some reservations) “Ethicists and
patient-safety advocates are optimistic about the promise but also point to
limitations and potential downsides, especially if the tools aren't carefully
rolled out by healthcare providers and software developers. The research, they
say, should be subject to the supervision of institutional review boards and
the same rules of informed consent as traditional studies.”
That’s a wrap – thanks again for reading!
All
comments and suggestions are welcome; please let me know what you think.
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"
