Saturday, September 20, 2014

That Was The Week That Was - Issue 28

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

This week lots of different measures of the uninsured, a look at enrollment numbers, (another) reminder of how tough the next open-enrollment period will be, more cost info (both good and bad), an Institute of Medicine report on end-of-life care, and more.   (You'll note I've made the section heads larger - at the request of a reader the idea is to allow people to better skim to their areas of interest, let me know what you think.)

ACA: Polls/Opposition
The week started off with three sets of numbers being released regarding the number of uninsured in the US:

The Census Bureau released two sets of numbers, both for 2013. The Current Population Survey (CPS) is the "gold standard" for these numbers, but due to a change in methodology in 2013 it only shows numbers for the year with no comparisons (the idea was to create the new baseline before the major impacts of the ACA took place including being before the first open-enrollment period). The American Community Survey (ACS) is a smaller survey that also provides numbers regarding health coverage.  Methodology was not changed, so numbers were released on a state level showing the difference between 2012 and 2013. (Health Insurance Coverage in the United States: 2013 (Primary Source))

Additionally, the CDC’s National Center for Health Statistics released its first-quarter health insurance survey for 2014.  Again no change in methodology so changes year to year were given. (Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2014 (Primary Source))

If that wasn't going to be confusing enough, here in Maine, the 2013 data, bucking the national trend, showed a decrease in the number of uninsured between 2012 and 2013 (not, 2014).  Maine along with New Jersey were the only two states to show such a decrease (Number of Mainers without health insurance rose 9 percent in 2013).  Note that the margin of error was almost as large as the decrease, so we don't want to over interpret the finding.  However, a review of the demographics showing where the decline took place did show that it may have been caused by the reduction in Medicaid eligibility that went into effect here last year (Data on uninsured doesn’t explain Maine’s increase - But two analysts say increases in certain demographic groups suggest that shrinking state Medicaid rolls is a likely reason.).

Here in Maine, as in many states across the country, the tale of implementation is truly a tale of two cities.  Those eligible for marketplace subsidies and/or living in states that have expanded Medicaid have benefited, while those who would have been eligible for the expansion but are living in states that haven't expanded are left out. 

For 2014 the national numbers showed a drop in the number of uninsured (Number of Americans Without Health Insurance Falls, Survey Shows).  However, these numbers only represent the first quarter of 2014, so the late surge representing about half of the enrollment is not included (New Estimates on Health Coverage Are Accurate but Outdated).  To my mind, the most robust numbers we have so far are still the Gallup numbers released earlier.

Also this week, HHS released a "snapshot" of the amount of people covered (and paid!) as of August, and it was a good number:  7.3 Million People Have Obamacare Coverage  "But the updated enrollment figures still beat the Congressional Budget Office's expectations. CBO estimated that the exchanges would cover about 6 million people this year, after accounting for churn."

In addition to beating the CBO forecast, it also put a lie to the cooking the books theory that emerged when the eight million number was announced in March: Obamacare Critics Said Obama Was 'Cooking the Books.' New Data Shows He Wasn't.  When the eight million was released, everyone knew that the full number would not end up enrolled.  Estimates ranged from 80% and lower to 90% - one way to interpret the 7.3 number is that it represents 90% of the original number, so 90% paid.  The churn that inevitably occurred netted out even - those who signed up during special enrollment periods (due to life changes, etc) balanced out those who dropped off (due to reasons like newly available employer coverage, etc.). 

So how are all those enrollees doing?  A Commonwealth Fund survey finds that Majority happy with ObamaCare plans.

Meanwhile, we continue to see that the connection of health reform to the President hurts it's popularity.  In one example: Survey: Republicans Like Obamacare a Lot More if You Call It by a Different Name and in another: Health Law Falls Flat With Kentucky Voters, Even Those It Helps.

The bottom line is that On health care, Obama and the ACA can’t win no matter what.

ACA: Premiums
As we reported last week, the Maine Bureau of Insurance has released the final marketplace rates for the next enrollment period, as we saw Premiums for Obamacare plans in Maine dip or remain flat for 2015.  Nationally, we can see the situation through a Commonwealth Fund survey: Are Americans Finding Affordable Coverage in the Health Insurance Marketplaces? Results from the Commonwealth Fund Affordable Care Act Tracking Survey.

ACA: Marketplaces
Looking towards the next open enrollment, as more and more details of the process come out, we find more cause for concern (Hurdles for Obama health law in 2nd sign-up season).  With the new process, if someone does what they should and go in to update their financial information, "...If they like their current coverage, they can renew it by entering the 14-digit identification number for their health plan. Or they can search for the plan in the online catalog of private insurance options known as Plan Compare."   (Health Law Has Caveat on Renewal of Coverage). Not exactly user friendly.

Regarding the 115,000 immigrants to lose health coverage by Sept. 30 because of lack of status data it was announced that the Feds give immigrants more time on health care.  For an in-depth review of what's going on, as we often do we turn to Tim Jost: Implementing Health Reform: Resolving Income-Related Data Inconsistencies.

There's been more discussion this week regarding healthcar.gov's security as a result of Probe: HealthCare.gov website must boost security.  While this is almost certainly true, I would humbly point out that the same can probably be said about any website.  To date, there have been no breaches of any confidential information on the site.

ACA: Employers
One of the innovations in the law for small employees is the introduction of employee choice to the small group market.  While we won't be getting it here in Maine until next year (2016 plan year), if you'd like to understand more about the topic Health Affairs put out a Policy Brief on the topic: Employee Choice , a long read but it does an excellent job explaining the issue.

ACA: Other
While no major developments on the Hobby Lobby front, Vox takes a look and sees that After Obamacare, two-thirds of insured women now get their birth control pills free.  Although there is a new concern as Rise Of Catholic Insurance Plans Raises Questions About Contraceptive Coverage.  And finally on the birth control front, Planned Parenthood is testing a new way to provide services: Birth control a few clicks away: But will app discourage exams?

Kaiser took a look at how the Health Law Tempers New State Coverage Mandates.  Remember the law says that if states pass new mandates, the state has to pay for them, this report looks at the issue overall and ways states are trying to get around that provision of the law.

Costs
A new Health Affairs paper reports that $1.43 of every $100 in America goes toward hospital administration. As Sarah Kliff puts it in her report: "This reflects something particular about the American health care system — namely, it's a complex mess."

In addition to spending on administration, we spend a lot on technology - some of it unnecessary.  As a proton therapy center closes, some see it as a sign I see it as cause for celebration!  " “I look at this closure as a sign that insurers are finally empowered to say this is a dubious medical technology” in the treatment of patients with prostate cancer, said Amitabh Chandra, director of health policy research at the Harvard Kennedy School of Government. “The 'build it and they will come' philosophy around these centers is being questioned.”"

Thinking about proton beam therapy begs the question, How much money do we waste on useless health care?  The article looks at the measures of waste from the Dartmouth Health Atlas and questions around its methodology.

CMS announced this week that New Affordable Care Act tools and payment models deliver $372 million in savings, improve care.  Here's additional coverage: Medicare ACOs improve quality, have mixed results on slowing spending, CMS says - while the story has a bit of a negative spin, it still contains lots of interesting information.  To those who say only some of the ACOs are working, I say that's why it's a pilot!  We may not yet have the perfect formula, but it seems clear the theory is sound.

As part of the changing landscape, we've seen a rush of hospital mergers.  This makes the FTC and Insurance companies (and me) nervous:  F.T.C. Wary of Mergers by Hospitals " “Hospitals that face less competition charge substantially higher prices,” said Martin S. Gaynor, director of the F.T.C.’s bureau of economics, adding that the price increases could be “as high as 40 percent to 50 percent.”" and Insurers Fight Hospital Mergers As ACA Snubs Fee For Service Medicine.

At the same time, you have Anthem (an insurance company) entering into a new partnership with hospitals.  Business Week observes The Vanishing Difference Between Hospitals and Insurance Companies and a local account of how the New Anthem Blue Cross plan takes on Kaiser.

Also on the cost control front, a report that One Way to Control Health Costs: Health Savings Accounts.  As we've observed before, the problem with these plans (and results) is they don't differentiate between preventing unneeded care and preventing needed care - they end up doing both.  So I ask, are they controlling costs by limiting access?

And finally, a cautionary note - yes, nationally we now have guaranteed issue and no pre-existing condition exclusions, but where there's a will there's a way, here is a look at How Insurers Are Finding Ways to Shift Costs to the Sick.

Medicaid
Funding for CHIP is set to run out in September of 2015.  The Fate of Children’s Insurance Program Is Called Into Question at Senate Hearing.  We'll be talking more about this as the year progresses, for now if you'd like more background on the topic: FAQ: Children’s Health Insurance Program’s Future Is Unclear Under The Health Law

A look at how Premiums may prevent low-income residents from enrolling in Medicaid.

And a Medicaid specific reminder that if you want a program to be popular, don't connect it to the President: The Three Words That Shift Views On Medicaid.

A series of focus groups across the country took a look at what new Medicaid enrollees think of the program: Millions have joined Medicaid under Obamacare. Here’s what they think of it.  While most are pleased, the results highlight some continuing access issues.

On a state specific front, bad news in Virginia as Va. legislators approve budget deal, reject Medicaid expansion.  But good news as in five states, including Maine, Elections poised to expand ObamaCare with the possible election of Democratic governors.

Medicare
CMS announced Medicare Advantage rates for 2015: Press release: Medicare Advantage enrollment at all-time high; premiums remain affordable (Primary Source) and at the same time U.S. says Medicare Advantage enrollment at all-time high.  This in spite of the provisions of the ACA that work to reduce payments to Medicare Advantage plans.  Yet another example of the doomsayers getting it wrong.

Drugs
In a positive, if long overdue move, a new initiative announced by the White House  Aims to Curb Peril of Antibiotic Resistance.  While some criticize the plan for not going far enough (especially with respect to the use of antibiotics in food production), it puts focus on the problem and starts to address it.  Which is further along than we were before the initiative was announced.

And the good news keeps on coming as the National Partnership to Improve Dementia Care exceeds goal to reduce use of antipsychotic medications in nursing homes.  These drugs have for too long been used inappropriately, now the usage statistics are moving in the right direction.

And yet one more positive development (before we get back to the usual state of things) as the F.D.A. Panel Backs Limits on Testosterone Drugs.  For those not familiar with the issue, "low T" or low testosterone, it is a made-up condition promoted by manufacturers of testosterone to boost sales. Now some focus is being put on these inappropriate practices.

Lots to report in this week's Sovaldi update.  First, it seems that in preparation for a new version of the treatment coming out soon, The new $84,000 hepatitis C treatment is losing momentum, for now.  But if you thought Sovaldi treatment cost was already high, just wait as Gilead to raise price for new hepatitis C drug above $84,000.  Although the Maker of Hepatitis C Drug Strikes Deal on Generics for Poor Countries the conditions of the deal insure that the lower cost versions will not be available here.

One alternative to dialysis centers is (for some) the option of in-home dialysis treatment.  For suitable patients, it has many advantages of going to a center several times a week to be hooked up to a machine.  Unfortunately, Shortage of in-home dialysis solution has patients worried and is limiting new patients from trying the treatment.

System Transformation
Regular readers know that I find it appalling the way we handle end-of-life care in this country.  I'm not the only one as the Institute of Medicine released a 500 page report this week looking at end of life care, making very specific recommendations (Panel Urges Overhauling Health Care at End of Life).  The conversation, and changes are long overdue.  The ACA tried to move this issue forward, but thanks to the death panel myth was unable to do so.  It’s time to bury the ‘death panel’ myth for good. Is this the way to do it?

In the context of this new report, Vox has a great interview with Ezekiel Emanuel, head of the Department of Medical Ethics and Health Policy at Pennsylvania University: Doctors wanted to extend life. Instead they extended death.

On the vaccination front, an appalling statistic as Wealthy L.A. Schools' Vaccination Rates Are as Low as South Sudan's.  There is just no excuse for this clear disregard of science.  And speaking of no excuse, there is none for the comments and damage done by, and selfishness reflected in, the work of Bob Sears: Bob Sears: Public health isn’t something his parents need to think about  " His white, affluent, Orange County kids can’t be bothered with needles. Sure, it’s no good for public health, but public health isn’t something his parents need to think about."

Several items to report on EHRs, or Digital Records, or whatever the kids are calling electronic medical records these days.  First, Frustrated AMA Calls For ‘Action Plan’ On Digital Records.  There is no doubt that the state of the technology leaves much to be desired.  Here is one doctors perspective on 5 things EMRs should learn from social media.

But there is so much promise, if we can just figure out how to do it right.  One step forward as Cerner and Athenahealth say integrating with Apple's mobile health service (they are two of the three largest EHR companies).  

Extending our look at digital information, we know a very small percentage of us account for the majority of dollars spent on health care.  While the work with Apple has potential to be helpful, Drew Altman reminds us that we need the technology folks to focus on the chronically ill (Needed: Apps That Focus on High-Need, High-Cost Patients).

A few more items of note this week:

And finally, since I just spent a week on Prince Edward Island (that's why I'm a day late publishing), it seems I should say something about the Canadian health care system.  But since I was more focused on celebrating my 25th anniversary and eating fish & chips, I'll leave it to Dr. Phil Caper to do it for me:  The troubling way we pay hospitals in Maine and throughout the US.

Thanks for reading!

All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!
Funded by support from the Maine Health Access Foundation
*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
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