Friday, May 23, 2014

That Was The Week That Was* - Issue 11


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


This week while the Veterans Affairs scandal dominated the headlines, there were many other health care developments:  New information about how much is being spent to oppose the law, more information on premiums, a few Medicaid and Medicare updates, lots of information on unnecessary spending on pharmaceuticals and more...  So let's get started.

VA
Although not directly related to the ACA, we'll start here.  I won't pretend to do justice to the full scope of the problem, but there are a few points I want to note.  Let me start by saying this is a disgrace.  Our veterans have served us and deserve, as we all do, access to appropriate treatment when they need it.  Clearly, there is a problem that needs to be addressed.  That said, the VA has at times in its history been a trendsetter in healthcare (initial adoption of EMRs is one example) and by all accounts, once seen by providers the care provided is still excellent.  These facts and others are being distorted in some of the coverage (I'm sure you're shocked).   You may have read that "40 veterans died" as a result of the waiting list problem.  What actually happened is that 40 veterans died while waiting for an appointment - sad to say that chances are most would have died anyway.  Again, I don't want to minimize the issue, but let's be mad about what really happened.  Some decent reviews of the issue can be found here The VA scandal, explained ad here Everything you need to know about the VA — and the scandals engulfing it and here History and Context of an Embattled Department of Veterans Affairs and finally here The Veterans Affairs Scandal Was Decades in the Making: Yes, you should be angry. But at whom?

Burwell
The Senate Finance Committee voted overwhelmingly (21-3) to confirm her (Burwell gets committee approval for health post) although there are still some who want to make more of a spectacle of the proceedings (Conservatives Want a Bigger Obamacare Fight Around HHS Nominee).  Even with the objections, she is expected to be confirmed sometime in June when the Senate returns from their Memorial Day recess.

ACA: Polls/Opposition
Some mind boggling numbers on how much has been spent on political ads relating to the ACA.  A  showed that Study: Political TV ads on health law total $445M with spending on negative ads outpaced positive ones by more than 15 to 1.  Remember that communications problem supporters of the law are still having swaying public opinion?  Obamacare Buried By Avalanche Of Negative Ads probably has something to do with it.  And it's still going on:  $10-million ad campaign joins 'avalanche' of anti-Obamacare ads.

One writer looked at How The Army Solar Power Program Is Like The Affordable Care Act.  Note that the answer is not my interest in both topics - rather it is that in the face of extreme opposition (financed by a pair of brothers who shall remain nameless) the success of both is starting to change the dialogue.

The week wouldn't be complete without more polls on the ACA and its impact on the mid-term elections.   Still six months out we have competing views on what effect the ACA will have.  Here is some of this week's coverage: Morning Plum: What does the polling really tell us about Obamacare?, The Politics Of Health In 2014 Aren’t What You Think.

ACA: Premiums/Costs
While no new rates were released this week, lots of talk about what is to come as well as a look at the impact that competition in the Marketplaces had on this year's rates.  The study asked the question How much lower could Obamacare premiums be with better competition? and answered it Study: Limited Competition Raised Obamacare Prices.  The Marketplaces were designed to increase competition, in states where there were more options that proved to be the case.  In many states (including Maine) we expect more insurers to participate in the Marketplace for the 2015 plan year (Insurers Joining More Obamacare Exchanges for Next Year).  That will help keep rates down.

With the topic of premiums getting so much attention, several attempts to explain how the process works.  If you always wanted to be an actuary, then you'll find this one fun: What to Expect for 2015 ACA Premiums: An Actuary Opens the Black Box.  If not, then this might be helpful Putting 2015 Health Care Premium Rates into Context.  And as Insurers, regulators prepare to negotiate 2015 health coverage costs I found Report: Fear of high ObamaCare premiums ‘unfounded’ to be reassuring.

Last week we reviewed the three "Rs" and budget neutrality.  The administration added some clarity to help insurers appropriately set their 2015 rates by saying that Federal funds earmarked to offset Affordable Care Act insurer losses.  But Critics call Obama funding plan for health insurer losses a 'bailout', even though the funding is temporary and designed to smooth out the transition period.

While the law is trying to increase access, it is also trying to rein in costs.  Here is a helpful review of one way that might happen: Meet Obamacare's secret weapon in the war on exorbitant health-care costs.

We all know that health care policy is complicated -at times a desired result has undesirable impacts.  Health Care is not a jobs program, so even though it is unfortunate when individuals lose their jobs, if we are to cut spending it is inevitable that some positions are eliminated as the system becomes more efficient.  We saw some small signs of this occurring this week with reports nationally Affordable Care Act, spending cuts slow health care hiring and locally MaineGeneral Health eyes budget that would lay off 16 employees, cut 128 positions.

ACA: Marketplaces
A reminder that the ramifications of some of the healthcare.gov's problems have yet to be resolved.  Federal health-care subsidies may be too high or too low for more than 1 million Americans.  This does not necessarily mean that a million people will have their subsidies adjusted, but it does mean there is a lot of work still to be done resolving these discrepancies.  And while $250K fine for lying on health insurance forms is the regulation, we don't expect very many will end up paying that size penalty (note that is for willfully lying, not for inadvertent mistakes).

In addition to completing healthcare.gov, there are other reasons that Obamacare enrollment doesn’t get any easier going forward.  Two of them are getting new people to enroll and getting those already enrolled to renew. 

Regarding functional websites, It’s crunch time for Obamacare’s broken exchanges.  We know that several states will be either changing vendors or using the Federal Marketplace (Health Site Under Fire, Nevada Alters Path).  And in an effort to clarify why some states had so many problems, US subpoenas Oregon insurance website documents to aid the investigation.

ACA: Employers
I wrote last week about the law that passed the house to amend how expats were handled under the ACA.  Here is a very helpful analysis detailing some of the law's problems by our friends at Georgetown Universities Health Policy Institute: The Expatriate Health Coverage Act: Like “Using a Bat to Swat a Fly?”.

Some agitation this week over the concept of "reference pricing".  Although nothing new happened, a few lines in regulations previously released were rediscovered.  The New Republic takes a looks at the issue : A New Obamacare Detail That Could Save You Some Money—Or Cost You Even More: Economists love this idea, consumer advocates hate it, and both may be right as does Tim Jost: Implementing Health Reform: Third-Party Payments And Reference Pricing.

ACA: Other
Last Friday, CMS released final rule for Exchange and Insurance Market Standards for 2015 and beyond (CMS Announcement).  I've previously described this for MeHAF grantees.  For those interested who have not seem my summary, it's copied at the bottom of this post. 

The Center for American Progress released a report saying that in order to continue successful implementation of the ACA A New Management Structure for a New Phase of the Affordable Care Act is needed.  Their bottom line is that the White House needs an ACA CEO. 

Last week we also reviewed the new recommendations regarding HIV prevention.  The question was then asked A Reader Asks: Are Insurers Required To Cover HIV Prevention Medication Recently Recommended By CDC?  The answer is no, since the recommendation was not made by the body specifically referenced by the ACA with respect to what preventative services are covered.

And finally, before we leave the ACA for this week, a comment by retiring Senator Rockefeller:  Senator: Race is part of criticism of Obama health law.  He said (and I personally agree) that while there are many reasons why individuals object to the ACA, one of them, for some people, is the race of the President.  When pressed, Rockefeller stands by Obama race remark.

Medicaid
Good reviews of how some Republican Governors  found it impossible to turn down the money associated with Medicaid Expansion: Republican governors have found something they like about Obamacare, The right starts to fold on Obamacare: How conservative governors are suddenly coming around (although we note with sadness that it hasn't happened here in Maine yet).

Some additional thoughts on last week's announcement by Gov Pence that even he saw the wisdom in accepting Federal Funds:  Indiana’s Gov. Pence taking the Obamacare money and running with it.

Medicare
Medicare continues to work to cut spending without jeopardizing care: Medicare May Be Overpaying Hospitals For Short-Stay Patients and Following Abuses, Medicare Tightens Reins On Its Drug Program and Bundled payments could cut Medicare fraud, experts say.

Drugs
Sometimes we pay more because one drug is used instead of another for no good reason.  We've talked before about how the use of Lucentis instead of Avastin is wasting money - now we have some dollar figures and they are not pretty:  Eye Treatment for Seniors: How Lucentis Wastes More Than $1 Billion per Year

And sometimes we pay more because drugs are used in general for no good reason: Thousands of Toddlers Are Medicated for A.D.H.D., Report Finds, Raising Worries and Way too many doctors are prescribing antibiotics in error, study says.

And sometimes we pay more because the price of a drug is obscene, even if it is the right drug used at the right time:  U.S. health insurers say Gilead hepatitis C drug too costly

And finally, sometimes we pay more because the "free market" pushes us in  that direction even though "...for many patients the profusion of choices has often led to confusion, not better treatments, as well as skyrocketing costs." (Type 2 Diabetics Face a Flood of Drugs and Tests)

Costs
Information on the cost of large employers covering their workers (note that this cost includes what the employees contribute).  This number will be important as we approach 2018 and the imposition of the "Cadillac Tax" on these plans *Health insurance coverage now costs $23,215 for a typical family).  For now, the Study: Care costs continue slower growth in 2014.

Price transparency is one way these costs might be kept under control.  One estimate is that Solving the mystery of health-care prices could save $100 billion.  (Also see the information in the employer section on "reference pricing".)

There are times when we need to spend a little more now to keep costs down long-term.  The care of chronic illnesses is one of those cases.  If there is too much of a barrier to the maintenance drugs then people will skip them and end up with acute problems.  That's why some advocate Why Patients With Chronic Illnesses Should Pay Less.

System Transformation
Need a reminder of how bad things are?  Take a look at this video and let me know if it makes you laugh or cry (or both): The insanity of the American health care system, in one hilarious video.

Meanwhile, there are efforts to bring our hospitals into the future (or at least the present) Athenahealth CEO Jonathan Bush: A prescription for fixing hospitals: Health insurance reform isn’t perfect, but it’s here. Now it’s time to remake how medical centers operate and The Hospital Of Tomorrow: Redefining Hospitals Under The Affordable Care Act.

Fascinating work around making the patients full "chart" available to the patient.  Opening Up Clinicians’ Notes—The Robert Wood Johnson and Cambia Health Foundations Funding a Movement and Pilot at Boston’s Beth Israel Deaconess gives patients electronic access to therapists’ notes

Reminders that Health care is ultimately a social enterprise and How Being Poor Makes You Sick.

Several cautionary notes out this week:

And finally, this week's laundry list of articles talking about the transformation taking place around us.




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"




Review of last week's CMS final rule for Exchange and Insurance Market Standards for 2015 and beyond. 

Here are links to the information:
CMS Announcement - General announcement

CMS FAQ - Technical, most of you can ignore

Tim Jost Blog Part 1 - "This post will address five of the most important and controversial issues addressed by the final rule: the regulation of navigators; changes in the premium stabilization programs; the regulation of fixed-indemnity plans; provisions for state regulators to veto employee choice in the SHOP exchange for 2015; and procedures for enrollees to obtain an exception to formulary restrictions in exigent situations. "

Tim Jost Blog Part 2 - "This post covers the remaining issues. It will also analyze guidance issued on May 16, 2014 by the Centers for Medicare and Medicaid Services and the Internal Revenue Service."
Some of what I consider the highlights:

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