That Was The Week That Was - Issue 34

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

Counting - that's our theme for today.  We look forward to counting new ACA enrollments.  With open enrollment beginning in just two weeks we'll look at some new resources.  We also look forward (this time with some trepidation) to watching the count of votes on election day - and the number of lives that could be impacted by the results as states choose to either expand Medicaid for the first time or roll back their expansion.  We'll finish up this week with the count of 1, the number of Ebola cases in this country.  You would think it would be one million based on the public hysteria.  All that counting and more as we take a look at this week's developments.

ACA: Polls/Opposition

With next week's election and the probable takeover of the Senate Republicans strategize attack on Obamacare if they win the Senate.  The behind closed doors sentiment that they still won't be able to repeal the law has led to the need for McConnell reassures GOP on Obamacare opposition.  While any full repeal would be vetoed by the President, it seems there is harm that can (and will) be done around the fringes.  We'll be watching closely.

A new analysis released this week showed that Obamacare brings Democrats backlash, not benefits.  The study looked at a variety of polls over time and found that " Only 47 percent of Americans agree that it’s the government’s job to make sure everyone has health coverage, down from 69 percent in 2006, the analysis found."  It seems all the negative attacks have impacted how people approach the fundamental goal of the law.  And a new poll that was part of the study showed that "31 percent want to see Obamacare repealed, (another) 23 percent want it scaled back."  So fully half the country is not on board.

ACA: Court Cases

Remember several months ago when Speaker Boehner said that the House would be suing the President? Well Despite hype, House still hasn’t sued Obama.  In fact Boehner has hired two law firms to sue President Obama. They've both quit. Perhaps the law firms thought better of it since the suit seems to have no basis (The Congressional Research Service Finds that Boehner’s Lawsuit Has No Legal Basis).

In other court news, it has been reported that at today's conference the Supreme Court will talk about taking up the subsidy challenge: "The plaintiffs in the King case appealed to the Supreme Court. The justices are scheduled to discuss the issue Friday in conference, behind closed doors. At that point, the justices could decide to hear the case, to not hear the case, or to put off a decision until a later time, called re-listing it.  ...  The court likely will re-list the case, McElroy predicted. The Court prefers to take cases when there's a split in opinions between circuit courts, and right now there is no split because the D.C. Circuit voided the panel ruling in Halbig. Obamacare opponents have urged the high court to take the case now even without a split, hoping the conservative majority on the court will reject the premium subsidies." (Will the Supreme Court accept the Obamacare subsidy challenge Friday?)

At the same time, the five who were committee chairs at the time the law was passed have a letter in the Washington Post: Affordable Care Act opponents are cherry-picking their history "This interpretation is wrong. As members of Congress who shaped and debated the legislation, we want to set the record straight."

And of course Hobby Lobby, the case that keeps on giving as a Federal judge blocks new HHS workaround for birth-control coverage.  As you recall, the Supremes said that CMS had to rework the procedure so that objecting employers were not "complicit" in supplying birth control. According to this one Florida judge, letting the government know you're not supplying the benefit is going to far... We'll be hearing more as CMS continues to try and figure out a process the courts will allow (while they may already be there we won't know that until this decision is appealed).

ACA: Premiums/Costs

A lot is written about the ACA and of course I can't cover it all.  But now and then I read an anti-ACA piece that is just so wrong, I have to comment.  Here is this weeks: Now There Can Be No Doubt: Obamacare Has Increased Non-Group Premiums In Nearly All States - So much wrong my head may explode...  To save space (and my sanity), I'll limit my critique to two key points.  One, the plans before and after are not comparable, many non-compliant plans had lifetime limits and no out of pocket maximums (remember, this is a bad thing - almost 3/4 of personal bankruptcies included medical cost as a precipitating factor) and did not cover preventative services with no coinsurance.  Two, the ultimate goal of the ACA is to keep people healthy, but that takes time - some additional upfront costs now should reap better insurance experience later.  We'll leave it at that.

ACA: Marketplaces

Only about two weeks to go before this year's open enrollment starts (on Saturday November 15 - let's not talk about why they left it on a weekend). So in spite of the public not focusing on this, we need to. 

For those involved in the process, a new Navigator Resource Guide from the Center of Health Insurance Reforms (Georgetown University Health Policy Institute) and the Robert Wood Johnson Foundation "This guide is focused solely on the private insurance reforms of the Affordable Care Act, including the health insurance marketplaces, rating, benefit and cost structures, and premium tax credits. It is intended to supplement the Navigator training available from the U.S. Department of Health and Human Services. It is not intended to be a comprehensive, stand-alone resource for all the reforms of the Affordable Care Act. ... This resource is organized into sections that address how individuals may present themselves to Navigators, based on their insurance status and coverage options. It includes questions and answers developed in collaboration with the staff at the Center on Budget and Policy Priorities, the Georgetown University Center for Children and Families, and the Kaiser Family Foundation.”

There's no doubt it's complicated.  Some groups have more complications than others: For Families With Mixed Immigration Status, Health Insurance Can Be Puzzling and Lessons learned from LGBT Communities and the ACA.

But let's face it, most of us find selecting a health plan hard: Choosing a Health Plan Is Hard, Even for a Health Economist.  A recent study underscores that a Lack Of Understanding About Insurance Could Lead To Poor Choices "They know less than they think they know. That’s the finding of a recent study that evaluated people’s confidence about choosing and using health insurance compared with their actual knowledge and skills."

What, you don't think there is enough to deal with - how about this one: You’ve heard of HealthCare.gov. Now meet HealthCare.com  Yes, a competing site at .com instead of .gov - also selling health insurance, but without access to subsidies.  Too bad the concept of eminent domain doesn't extend to URLs...

Looking forward, some are trying to change the options available on the marketplace: 7 Democrats have a plan to make Obamacare cheaper. Here’s how.  Bottom line is they want to introduce an even cheaper plan (copper).  Given the affordability issues we've already seen with the Bronze and even Silver plans, this is not a good idea.  I'll have more to say about this next week but for now here is one taste of some of the affordability issues currently being faced: As Insurers Try to Limit Costs, Providers Hit Patients With More Separate Fees

ACA: Employers

As some of you know, I have been presenting at MeHAF's small business seminars on the ACA.  You can get information (and see videos) here: Enroll207 SHOP info.  I bring this up because of one of the points I discuss.  For some small employers, dropping coverage, so that their employees can access the individual marketplace (and subsidies), is a good decision.  It helps both the employer and the employee.  Bear that in mind as you read that  Small Firms Start to Drop Health Plans: Many View the Health Law’s Marketplace as Inviting and Affordable. 

Both the Urban Institute and the Commonwealth Fund took a look at employer sponsored coverage.  Both found little immediate impact on rates of coverage other than among the smallest employers (most of whom are not currently providing coverage anyway):

• Monitoring the Impact of the Affordable Care Act on Employers " Taken together, these results do not suggest a massive upheaval in employer-sponsored coverage under the Affordable Care Act as some have speculated. However, there are several gaps in the literature—particularly on how the Affordable Care Act will affect health care costs—where researchers and policy analysts need additional information to better understand the potential effects of the law on employers. Monitoring the effects of the Affordable Care Act on small firms should focus on areas where the expected impacts would be largest."
• What Will Be the Impact of the Employer Mandate on the U.S. Workforce? "Fewer than 10 percent, less than 0.03 percent of the U.S. labor force, might see reductions in employment or hours in the short run."

Also this week, At Honeywell, required biometric and medical testing prompt a lawsuit.  While wellness plans may (emphasis on may) help, they can only administered in such a way as to not harm employees.  Honeywell apparently went against those protections, prompting the Feds lawsuit.

ACA: Other

With the second open enrollment approaching, the New York Times took a deep look at the question Is the Affordable Care Act Working?  Here is a discussion of What to Look for in Judging the Affordable Care Act.

And here are some of their conclusions:  A Perfect Fit for Some, but Not Others.  And finally, Obama’s Health Law: Who Was Helped Most "The data shows that the law has done something rather unusual in the American economy this century: It has pushed back against inequality, essentially redistributing income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades."

Obamacare isn't just expanding health insurance. It's reducing inequality. "But for those who live in low-income areas, Obamacare has made a world of difference. The uninsured rate for residents of poor counties fell by 9 percentage points, from 26.4 percent in 20to 17.5 percent now."

But we know it has not helped everyone.  Probably at or near the top of the list of those it has not helped is Mississippi: Mississippi, Burned: How the poorest, sickest state got left behind by Obamacare. It is a long painful read.  Painful not because of the great reporting and writing, but because of the results.

One of the benefits of ACA compliant plans is the availability of preventative services with no cost sharing.  Kaiser has issued an updated fact sheet showing what that means: Preventive Services Covered by Private Health Plans under the Affordable Care Act.

It is insurer quarterly report time and the numbers are looking good, both for insurers and for ACA enrollment: Expectations high for health insurers' Q3 results, thanks to ACA.  As the Health care overhaul doubts ease for insurers the Insurers have big plans for 2015 Obamacare enrollment "U.S. insurers planning to sell 2015 Obamacare health plans expect at least 20 percent growth in customers and in some states anticipate more than doubling sign-ups"

Medicaid

In case you haven't heard, there is an election Tuesday and contrary to the popular misconception - it matters.  The Fate of Medicaid Coverage for 2,000,000 People Could Hinge on the Outcomes of the Midterm Election  Due to the Supreme Court decision that the Medicaid expansion is a state option, what happens locally is tremendously important.  Here in Maine it will impact 70,000 Mainers (and more): Think the Midterms Don't Matter? Tell That to 70,000 Poor, Uninsured People in Maine.

But that is a two way street and the Arkansas' Medicaid expansion model could hinge on election outcomes "Under state law, the Legislature must reauthorize the expanded program annually. Because it's part of the budget, passage requires support from three quarters of the members of the House and Senate."

On a different note, there appears to be good news ahead as Coming Medicaid plan rules will set new access standards "The recent OIG investigations will lead to stronger standards for network adequacy, including guidelines for how quickly a member should be able to get a physician appointment, Golden said."

And while the ACA Primary Care rate increase for Medicaid PCPs was supposed to only be temporary, many states are continuing them: State Plans for SFY 2015 While the map shows Maine as having extended the increased reimbursement, it is not final yet.  The Maine Medical Association reports: "DHS is committed to retaining the enhanced payment as part of its initiative to promote primary care.  State funds necessary are expected to be included in the supplemental budget to cover Jan 1-June 30 then put in biennial budget."  Look for an update from them early next week.

Medicare

Theory is easy, implementation is hard.  We've seen that time and again in the first full year of the ACA, but it's not unique to the new law.  A couple of cases where Medicare had some problems this week: Another whistleblower suit alleges Medicare Advantage fraud and  Medicare bought meds for dead people.

Drugs

Drug prices continue to be a concern.  "In a letter Tuesday to key congressional committees, the National Association of Medicaid Directors said lawmakers should consider everything from outright price controls on manufacturers to federal help for states trying to pay for the new medications" (States ask Congress to intervene on drug prices)

Of course we know one of the drugs prompting the new concerns is Sovaldi - so as Sovaldi fuels triple-digit rises in Gilead revenue and profits restrictions are being put on its use: Hepatitis C Patients May Not Qualify For Pricey Drugs Unless Illness Is Advanced.

There are ways you cut your own drug bill.  For instance You can use a placebo to treat a child’s cold - that's right, a study showed that a placebo was as effective as medications for calming a child's cold - and both were better than no treatment at all.

System Transformation

We know we have to treat the whole person - what goes on in the provider's office is just one part.  It should go without saying that having a roof over your head is critical: In Focus: Using Housing to Improve Health and Reduce the Costs of Caring for the Homeless.  And here is a specific look at poverty's impact on diabetes: Poverty’s Association With Poor Health Outcomes and Health Disparities ” A recent ecological study by Carl Stevens, David Schriger, Brian Raffetto, Anna Davis, David Zingmond, and Dylan H. Roby, published in the August issue of Health Affairs, showed significant associations between neighborhood poverty and diabetes-related lower extremity amputations (LEA) in the state of California, which adds to the growing evidence that where you live (not just how you live) may directly impact your health."

We are now officially in flu season, have you gotten your flu shot yet? This week we'll appeal to your love of your grandparents:  Why even healthy people should get a flu shot: to protect your grandparents. 

Rates for vaccinations in general are falling here in Maine, so As more Maine parents reject vaccines, public health experts consider a new pitch.  And here's one story of the ramifications: I've Got Whooping Cough. Thanks a Lot, Jenny McCarthy.

A few more items for your consideration:

• Doctors and Decision Fatigue - Doctors are people to, they get tired at the end of the day and that has implications
• Google working on pill that searches for illnesses - Sounds like science fiction, but it's developments like this that could be game changers
• Massachusetts town considers banning sale of tobacco products - It has to start somewhere...
• A radical cancer therapy: Don't treat " “What's unusual about [doctors],” Murray wrote, “is not how much treatment they get compared to most Americans, but how little.”"

Ebola

One - that's the current number of Ebola cases in this country.  From the public hysteria you would think people were dropping in the streets...  (Republicans call Ebola a federal government failure. It’s exactly the opposite.)  Unfortunately, once again in this country we are reacting emotionally instead of rationally.  You can all read as much on this topic as I can, so I won't attempt to provide a thorough update on the topic - instead I'll provide some resources (from people who know what they are talking about), talk a little about what's going on here in Maine and make one point about the military policy.

I'm not a doctor, I don't even play one on TV, but I know where to find them.  If you are going to click on one link in this section, here it is, the New England Journal of Medicine on Ebola and Quarantine.  Here, a bit more distilled are 3 reasons public health experts think Ebola quarantines are a terrible idea.  And finally for those who want to dive even further into the science: Assessing the Science of Ebola Transmission: The research on how the virus spreads is not as ambiguous as some have made it seem.

As you might have heard, here in Maine we have our own celebrity health care worker, Kaci Hickox.  To me she is a hero.  She has been on the front lines  treating Ebola patients in Sierra Leone.  Now she just wants to get back to her life, but the epidemic of fear is keeping her from doing so. Although the State's position keeps shifting, essentially they want to keep her isolated for 21 days, even though she has no signs of being infected. 

In a burst of rationality, many health leaders here in Maine have sent a letter to the administration supporting her.  You can see the actual letter here: Maine Voices: To fight epidemic of fear, we must be guided by science, not emotion.  And you can see our own Gordon Smith (Executive Vice President of the Maine Medical Association) on last night's Rachel Maddow show.  She gets to Maine at about minute 8, but it's all worth watching.  A key quote from Gordon is that the policy should be "based upon science, not based upon emotion or politics": Uncowed Kaci Hickox supported by state health leaders

And as I prepare to finalize this week's post, the courts had their say: Judge requires monitoring, won’t ban Kaci Hickox from public places on Ebola fears.  So as of now Science 1: Fear 0

Fellow Mainers, I can also offer you this consolation, we are not the only state where fear is running rampant.  In Connecticut Child Barred From School After Trip to Africa; Father Sues.  The good news is that after suing the child is being allowed back in school as of today.  But before we move on, note that the family visited Nigeria - a country without an Ebola outbreak and nowhere near those countries that are currently dealing with this. 

While debate rages across the states as to what their unique policy will be (in spite of the Federal guidelines) Hagel Approves 21-Day Ebola Quarantine For Troops.  This means that Soldier or civilian, Ebola protocols not the same.  I think this sends a bad message and as with the overreactions in some states, claims to the contrary is not based on any science.  I won't scream too load since these soldiers are doing vital work (and more are on the way) but it is another unnecessary hindrance to helping those in need.

Finally, a firsthand discussion of why these unnecessary restrictions hurt: The Media's Overreaction to Ebola Is Sending a Chill Through My Coworkers at Doctors Without Borders.

I've focused on the situation here, but as we know the real emergency is in Guinea, Liberia and Sierra Leone.  If you're interested in helping consider contributing to Doctors without Borders

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"

That Was The Week That Was - Issue 33

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

November will make change the lives of millions of people in this country. The results of the election on November 4 will decide if more states (including Maine) will participate in the Medicaid expansion. Then on November 15th open enrollment begins giving many access to quality affordable health care that they never had access to before.

This week we'll look at what's going on with the ACA including from new polls, open enrollment developments and ways to improve the law we'd be talking about if we lived in a world where so much energy didn't have to be spent defending the laws existence. Also data, dangerous drugs, end of life care and inevitably Ebola. Here we go.

ACA: Polls/Opposition

We'll start off with some good news. Although "health insurance" literacy is a problem for many, a recent poll found that Voters Know Insurance Basics Heading Into Open Enrollment. Among the survey's findings was that 77% of respondents could define a deductible (although the other 23% still need help).

On the other hand, this month's  Kaiser Health Tracking Poll found that Only 11 Percent of Uninsured Know About Obamacare’s Next Open Enrollment. With only three weeks before it starts, this result highlights the amount of outreach that will be needed.

On the political front, lots of drama as Gov. John Kasich’s view on Medicaid fuels two-day spat with AP. Basically, he said that the ACA wasn't going anywhere because it was helping people - he then rapidly walked back his comments (Ohio's GOP governor says Obamacare is helping people, then rapidly retreats). Nonetheless, in some respects This Republican Just Made the Best Obamacare Pitch of Any Politician. The key sentence: "The opposition to it was really either political or ideological. I don't think that holds water against real flesh and blood, and real improvements in people's lives."

ACA: Marketplaces

Secretary Burwell spoke to the American Academy of Family Physicians this week and told them: “We're going to need your help and your support just as much as we did last year, if not more”  (HHS chief rallies docs to boost ObamaCare enrollment).

We learned this week that Healthcare.gov's Ez Form Not For Legal Immigrants. Specifically, they will not be able to use the new 16 screen form and instead must use the old 76 screen one because they will automatically be classified as "complex cases". This issue joins the long list of things that could be addressed if more people were concerned about making the law work well instead of just criticizing it and trying to get rid of it (another example of this leads of the cost section below).

The Commonwealth Fund shared its thoughts on reenrollment with a useful overview: Keeping Covered: The Affordable Care Act’s First Reenrollment Period for Marketplace Plans.

Two reports were released drawing lessons from history to help with open enrollment. The first: Open Enrollment: Insights from Medicare for Health Insurance Marketplaces presents a cautionary note that while reviewing one's current marketplace plan during open enrollment is the smart thing to do, Medicare Part D experience says it's an uphill climb to get people to do so. The second: Report from the First Year of Navigator Technical Assistance Project: Lessons Learned and Recommendations for the Next Year of Enrollment is a new report from Georgetown and RWJ drawing lessons from last year's experience.

ACA: Employers

The Wall Street Journal takes a look at how some businesses are reacting to the law: Restaurant Owners Look for Creative Ways to Escape Health-Law Penalties (no subscription required for this article, don't ask me why, when the Journal enforces its pay-wall remains one of life's great mysteries). Unfortunately, instead of accepting the law as a cost of doing business some look for creative ways around it.

Also this week, Sam’s Club to launch a private health insurance exchange. Private exchanges have been around (and growing) for large firms, but this is specifically geared to small employers. Remember, private exchange participants are not eligible for any subsidies (for either individuals or the small business). What they do offer is a way for employers to switch from a defined benefit health plan to a defined contribution plan - they just designate a sum of money for each employee - what they buy with it is up to them (and there are no guarantees there will be something affordable for that sum of money).

On the public exchange front, Obamacare’s small-business exchanges to see major changes in the coming months. This article looks at some state specific small business marketplaces as well as the federal one.

ACA: Court Cases

The Rand Corporation produced a rather sensationalist report this week reacting to the Halbig case: Assessing Alternative Modifications to the Affordable Care Act Impact on Individual Market Premiums and Insurance Coverage (Primary Source). The report evaluates what would happen to the Marketplace if the subsidies went away. However it assumes they go away in every state and ignores the real possibility that even if the suit was ultimately successful before the Supreme Court, there are ways to still use the federal IT platform and call it a state exchange (marketplace). Here is a review of the report from the Washington Post: How the Supreme Court could still wreak havoc on Obamacare

Also from our friends at the Washington Post: The ongoing Hobby Lobby battle: Who else can get an exemption? The easiest way to describe where things stand with respect to the Hobby Lobby battle is with a one word summary: "confused".

ACA: Other

More guidance out this week from CMS with respect to the Basic Health Program. This is an option open to states as an alternative way to cover those earning between 133% and 200% of FPL. You can read the CNS fact sheet here: Fact sheets: Basic Health Program Funding Methodology Proposed Notice. Maine's Health Exchange Advisory committee discussed the concept and heard a presentation on the plan and alternatives. The September 22 Meeting Materials  include the presentation (towards the end).

Other technical guidance has been released recently, for a review we turn to Tim Jost's Health Affairs Blog: Implementing Health Reform: The Qualified Health Plan Federal Exchange Participation Agreement And More (fairly technical but of interest to some of us).

RWJ released a report: Essential Health Benefits: 50-State Variations on a Theme. This will be extremely important information in 2015. Remember, originally, there was going to be one national definition of essential health benefits. Instead, each state has their own definition, but that is only for the first two years (2014 and 2015) of implementation - anytime now we'll hear what the plan is for 2016. Regardless of what the plan is, expect fireworks after the announcement.

"With an estimated 25 million new people becoming insured over the next few years, a coalition of family physicians has a message for the country: Don't forget about us.  ... The timing is right for the group, which on Thursday announced a five-year, $20 million campaign aimed at promoting the importance of primary care. The flood of newly insured patients presents a big opportunity for primary care doctors, when you consider this: just one-third of uninsured adults said they have a regular doctor, about half the rate of the insured population, according to a 2013 Kaiser Family Foundation survey." (Primary care doctors to patients: Don’t forget about us).

Costs

On top of that list of issues to address to improve the law is the issue of affordability. From the "family glitch" to high deductibles, we know there are people who are not able to get the full benefit of health coverage given current circumstances. This was highlighted in the NY Times piece: Unable to Meet the Deductible or the Doctor. I will note that the piece looks at cases that fall into two broad categories. First there are those who may have been better served making a different choice on the marketplace such as a silver plan where they may have been eligible for cost sharing subsidies or even a more expensive gold plan. The focus on premium as opposed to overall cost during the year can lead to these types of problems. Second is the group that did everything right but nonetheless end up with greater costs than they can afford. Unfortunately in our system focused on health coverage instead of health care, these circumstances will inevitable arise.

This week HHS Secretary announces $840 million initiative to improve patient care and lower costs “The administration is partnering with clinicians to find better ways to deliver care, pay providers and distribute information to improve the quality of care we receive and spend our nation’s dollars more wisely,” said Secretary Burwell. “We all have a stake in achieving these goals and delivering for patients, providers and taxpayers alike.”  And more info here: Transforming Clinical Practices Initiative

Also on the cost front, reference pricing is back in the news. A review from Kaiser: More Plans Setting Spending Limits For Some Medical Services and a study published on the potential extent of savings: The incredible cost savings that are possible when patients can actually shop around. I do take issue with the headline (as I often do). While the savings are real, they won't fix the system (we've discussed other studies previously that looked at total savings possible). There is also this caution about the strategy: "Health care economist Uwe Reinhardt, writing in a separate JAMA editorial, says the early results seem to support expectations that transparency in health care can lower spending. But it only works, he cautions, if there's enough provider competition. "It is a point that is sometimes overlooked but is an essential ingredient for patients to benefit from knowing the price and quality of the health care services they purchase," he writes."

And speaking of competition (or lack thereof due to consolidation): Study: Medical costs up to 20% higher with hospital-owned physician groups "" Total spending per patient was 10.3% higher for hospital-owned physician offices compared with  doctor-owned organizations, according to the study. ... Costs were even higher when large health systems running multiple hospitals owned medical groups. Their per-patient spending was 19.8% higher compared with independent physician groups."

Much has been made of the Medicare cost slowdown. Upon further analysis it appears You may want to thank George W. Bush — not Obamacare — for the remarkable Medicare cost slowdown. It seems that Medicare Part D is a big part of what's happening: " In a recent analysis of the Part D slowdown, the CBO concluded that it can be almost entirely explained "by broader national trends in per-capita drug spending that occurred as a result of the pharmaceutical technological slowdown" -- as well as lower-than-expected enrollment in the prescription drug program. ... "The decrease in Medicare spending growth has already been a remarkable shift, and prolonging the slowdown in Parts A and B would be a tremendously important contribution," the pair write. "Unfortunately, though, the outsized role that Part D has played in the Medicare slowdown is bad budget news because it may prove fleeting.""

Medicaid

There may have been news out of Utah this week but we're not sure. Gov. Herbert: Deal is done with Obama administration on Medicaid alternative. There were no details released: "The governor expects to share details of his plan with legislators in mid-November, and there will be a 30-day comment period for the public as well." Additionally, we're not even sure if the deal is final: "David Patton, executive director of the Utah Department of Health, however, told lawmakers Thursday that negotiations continue on a few details, specifically a table of co-payments that low-income Utahans would make for medical services under Healthy Utah."

Drugs

Apparently, CVS wasn't satisfied to stop selling tobacco products in their stores, they want all pharmacies to do so. To achieve that, CVS has a plan to strong-arm other pharmacies out of selling cigarettes. They are planning to impose an additional copay through its Caremark pharmacy benefits manager business for drugs purchased in pharmacies that sell tobacco products. Expect to hear more about this. While the goal may be admirable it has the potential to end up costing consumers more money due to factors they have no control over. (Plus it sounds a little like using their PBM power to force customers to their retail pharmacies...)  Stay tuned!

Meanwhile, here are three stories where we know for sure consumers are being harmed:

• Dangerous Dietary Supplements Return to Store Shelves "The study found that two-thirds of the 27 supplements analyzed contained at least one unlisted anabolic steroid, prescription drug or banned substance. A majority contained the same drug or illicit ingredient that led to them being recalled by the agency."
• On an Antibiotic? You May Be Getting Only a False Sense of Security
• Warning: This Parkinson's drug can make you addicted to gambling, sex, or food

System Transformation

How do we know if a treatment is appropriate?  Is there some number that could be told to patients (and providers) to help them decide if a treatment is appropriate? "That number exists, and it’s called the number needed to treat. Developed by a trio of epidemiologists back in the ’80s, the NNT describes how many people would need to take a drug for one person to benefit. (The NNT for antibiotics in a case of acute bronchitis is effectively infinity, because the medicine is no better at curing the illness than a placebo.)"  A potentially crucial part of the movement towards evidence based case, you can read more about NNT here: This Man’s Simple System Could Transform American Medicine.

Atul Gaawande's new book on end of life care is now out. First a book review from Janet Maslin from the NY Times: A Prescription for Life’s Final Stretch (remember when Janet Maslin was their film critic? I miss her film reviews). And from our friend Ezra Klein, here are 9 lessons Atul Gawande taught me about dying. Meanwhile, on the same topic here in Maine, the most recent entry in the continuing series: Someone to watch over THE JOURNEY’S END.

Some focus this week on organ transplants and the organ shortage that exists: An organ shortage kills 30 Americans every day. Is it time to pay donors? and America's Organ Transplant Law Is Criminally Unfair to Donors.

One physician take a fresh look at EHRs and how they are doing: The EHR report card 2014: Has it gotten better? "While the software is not evolving as quickly as I would like, the ways that I interact with it are changing more rapidly. I’m always finding new (usually better and faster) ways of doing things."  He reaffirms that yes it has been slow going, but there is value to be had (unlike some who are ready to get rid of them all).

On the quality front, people in Maine had reason to be proud this week as the Washington Post said: Best state in America: Maine, for its hospitals. It's a nice headline, and it's true that a greater percentage of Maine hospitals got an A rating from Leapfrog than any other state, but that doesn't mean we're done. We have a lot to be proud of here in Maine but there is still a long way to go.

If you need a reminder that health care itself needs improving, here you are: Mistakes in Treating Childhood Fractures  "A pediatric orthopedic team at the University of Maryland School of Medicine examined the splinting technique used in 275 young patients, who averaged 8 years old. In 93 percent of the cases, the injury had been wrapped improperly, according to a study presented this month at the American Academy of Pediatrics conference in San Diego."

Ebola

And finally, inevitably, we'll talk a little about Ebola. Today (Friday 10/24) the number of cases in this country reams constant  - but that represents a swap of a new case in New York for a cured case (one of the Dallas nurses).

Ebola is a huge problem, but not here in the US. Here's a reminder of what real tragedy looks like: Video: Inside the Ebola Ward

Most of the coverage remains sensational, but so far policy remains restrained in that the Feds have not succumbed to pressure to institute a travel ban. Why not you ask?  The evidence on travel bans for diseases like Ebola is clear: they don't work. Instead we have The CDC's New Ebola Plan Is Better Than a Travel Ban. And while some argue Why new post-entry screening in the US is unlikely to catch Ebola, even this author ends up saying "it should avoid a travel ban, which is a good thing".

And while the Maine CDC creates its own resource page Ebola: Information for the Public the Bangor Daily News appropriately says: Worried about Ebola? Grab a bar of soap.

I took a long time deciding if I was going to include the next link or not - it's a song parody about Ebola - but I finally decided to share it along with the introduction provided by its creator:

"Ebola is NOT funny... ...but the absurd US media hysteria about the virus is ripe for some ZDogg ridicule!  So ZDoggMD Industries has once again teamed up with musical legend Devin Moore from the band Rabbit! to pull the plug on Ebola...or at least perform Ebola unplugged.  And as you watch, please send your thoughts (and hopefully some aid) to those suffering from this massive humanitarian tragedy in Africa, and our affected healthcare workers here at home."

EBOLA (A LOLA PARODY)

Interested in helping?  Consider contributing to Doctors without Borders

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 32

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

We are now less than a month from Marketplace open enrollment. So in spite of the fact that the media was obsessed with Ebola and decisions the Supreme Court was making without issuing any decisions,  there's still a lot of health policy to talk about. Candidates talking about repealing the ACA, getting ready for the 7 million enrolled in marketplace plans to reenroll, rural ACOs joining the party, Medicare open-enrollment starting and more. So here we go:

ACA: Polls/Opposition

We're in the height of campaign season. That means that candidates say things they know not to be true. So, even though no one thinks the ACA will be repealed, the GOP can’t give up Obamacare repeal talk. Also this week, we saw an actual "replace" plan. Ed Gillespie, Senate candidate in Va., unveils alternative to Affordable Care Act. We won't go into it in detail except to say that it rolls back the Medicaid expansion, eliminates the mandate and subsidies, and provides tax credits instead. In other words, it shifts costs to individuals - regardless of if they can afford it or not. It also lacks the systemic changes designed to actually bring costs down.

At the same time, a new poll about showing that people are still worried about their health care bills. These concerns seem to fall into two categories - those concerned with bills they may need to pay (such as those with a $5,000 deductible) and those who don't understand their coverage, and that they may be better protected than they know. We know that the out-of-pocket maximum still represents a burden to some people - although there is also the concern that some may have been eligible for cost-sharing  help if they had purchased a silver plan instead of something else. Bottom line, the data in this survey highlights the need for better communications, increased health literacy and a review of what is truly affordable:  Poll: Many Insured Struggle With Medical Bills

ACA: Marketplaces

November 15 and the start of the next open-enrollment period is right around the corner. Unlike last year, when until the very last minute we were hearing that everything would be fine, this year the Administration is being a bit more guarded: New strategy: Underselling Obamacare for Year 2. For example, they say the site "will be improved but won't be perfect" and are not releasing any projections for the three month open-enrollment period.

This year's open-enrollment will be fundamentally different because there are two distinct populations: Those enrolling for the first time and those who are back to reenroll - either in the same plan or a new one. This week, CMS kicks off effort to help Marketplace enrollees stay covered (press release). They announced that they were mailing letters (one of six different ones)  to individuals who had already enrolled in a plan and would need to reenroll to continue their coverage. Here is Tim Jost's explaining the process: Implementing Health Reform: Renewing Coverage For 2015

Less traumatic than the five stages of grief CMS provided this outline of 5 steps to staying covered through the Marketplace. The key here is that while most people could be automatically reenrolled in their current plan, it is in the individual's best interest to go back to the marketplace, update their information and compare plans to see if their current plan is the best choice. Along with the brilliant Andrea Irwin, I wrote a blog on the topic for the enroll207 website:  Avoiding "Scandalous" Marketplace pitfalls: put shopping for health insurance at the top of your “to-do” list.

And for another take on how to approach reenrollment, even though it's not Passover, here are 4 questions to ask before renewing health coverage. Finally on this topic, Robert Pear of the NY Times does a good overview piece, even if the headline writer doesn't seem to have read it closely: U.S. Says Consumers Must Renew Health Insurance Policies (you don't have to renew the policy you currently have).

Also this week a reminder from Kaiser that Consumers Whose Income Drops Below Poverty Get Break On Subsidy Payback.

ACA: Employers

A few weeks ago we talked about an online calculator from CMS that seemed to say certain plans without hospital benefits were "credible coverage". Until now CMS has not responded to requests for clarification. But finally, the Administration Signals Doubts About Calculator Permitting Plans Without Hospital Benefits.

A couple of looks at what's happening to employer costs. In the first, Obamacare Refutes Warning of Corporate America Cost Surge - the story reviews some of the dire predictions of what would happen to employer-sponsored coverage and how they have not come to pass. In the second, a look at renewal costs for businesses: Modest Premium Hikes, Higher Consumer Costs Likely For Job-Based Plans

That said, a survey for ADP found that Mid-sized businesses still very concerned about (and unprepared for) Obamacare.

ACA: Premiums

Why are some of the states with the most competitive Senate races seeing the biggest premium spikes?  "... a big factor, according to Levitt, is whether states promoted ACA enrollment and got enough customers to cover the costs of sick people. Louisiana, Iowa and Alaska — all states where the political leaders have been vocally opposed to the health care law — did particularly poorly in enrollment compared to their potential market of customers, he said.  ...   “Iowa is at the bottom of the list. Alaska’s not too far behind, and Louisiana is well below average,” Levitt said. He said Iowa enrollment has likely been hurt by the fact that Wellmark isn’t participating in the health insurance exchange." (An Obamacare October surprise?)

Here is a story that if not for the media being distracted would surely have gotten more national attention. Last year's most successful insurer on the Minnesota Marketplace announced a 63% average increase for individual customers. Once you pick your jaw up off the floor, two important things to keep in mind. 1) Their 2013 premiums were among the lowest in the country (they bought business but couldn't sustain it). 2) They will NOT be selling on the Marketplace in 2015 (so anyone with subsidies was going to be changing insurers anyway (Big jump for PreferredOne premiums).

ACA: Other

Remember the risk corridor payments?  Those are one of the ways that the ACA will smooth the transition for health insurers by spreading the risk of getting "sicker" enrollees among all insurers. Some opponents of the law have called this an "insurer bailout" - even though the idea is that it is merely redistributes the fees paid by the insurers. Opponents have tried to claim that it would require congressional action to make the payments, but that appears not to be necessary: GAO: Administration Can Make Health Reform’s “Risk Corridor” Payments.

Another day, another story about the high cost of prescriptions: Got Insurance? You Still May Pay A Steep Price For Prescriptions. This is what happens when you provide health insurance as opposed to health care - when you are sick, you do need to pay more. At least with the ACA, the amount you pay is capped with the out-of-pocket maximum - which would apply to specialty drugs covered by your plan, regardless of the co-pay. Of course for some, the out-of-pocket maximum of $6,350 is still a problem.

Costs

One of the favorite suggestions of opponents of the law is medical malpractice reform. They seem to think that this (along with selling insurance across state lines, which we won't discuss today) is a magic bullet for lowering costs. Unfortunately, the facts don't back them up as a new study looks at three states that have instituted significant limits on malpractice awards and have not seen the "expected" savings: Study: Don’t expect big health-care savings from medical malpractice reform

Accountable Care Organizations continue to be all the rage. In an attempt to extend the model to more rural areas, a new CMS loan program offers rural providers entry to accountable care. The idea is to provide upfront dollars to help the rural groups afford the infrastructure improvements to allow them to participate in the new model.

Medicaid

Some thoughts on additional states expanding Medicaid: Are Medicaid Boosters Too Optimistic?  The piece asks the question if it's realistic to expect the rest of the states to fall in line any time soon.

Also this week a new study says that the Spike in ER, Hospitalization Use Short-Lived After Medicaid Expansion "While the Medicaid expansion may lead to a dramatic rise in emergency room use and hospitalizations for previously uninsured people, that increase is largely temporary and should not lead to a dramatic impact on state budgets, according to an analysis from the UCLA Center for Health Policy Research released Wednesday."

Kaiser's annual Medicaid report was released:  Implementing the ACA: Medicaid Spending & Enrollment Growth for FY 2014 and FY 2015 (Primary Source).

Here is a brief summary: Many On Medicaid See Boost In Benefits As Economy Improves  and here are two more in-depth look at some of the results: Tracking Medicaid Enrollment and Spending and New Kaiser Survey Finds More States Intend to Extend Primary Care Rate Increase.

Medicare

While we're a month away from the Marketplace open-enrollment period, the Medicare one (which ends December 7) has already begin: Once-a-year Medicare open enrollment allows switch in Advantage and drug plans.

Here is a look at What’s In and What’s Out? Medicare Advantage Market Entries and Exits for 2015.

Meanwhile, not all is perfect as U.S. Finds Many Failures in Medicare Health Plans and there is A call for more scrutiny of private Medicare Advantage plans.

Drugs

We haven't talked about Sovaldi for at least a week, well this week it's time for "Son of Sovaldi" as Harvoni, a Hepatitis C Drug From Gilead, Wins F.D.A. Approval. This is a combination pill containing Sovaldi and another drug - previously the patient would have to take other medications along with Sovaldi, now it's a single pill regimen. But the cost issues have not gone away: Will ‘Son of Sovaldi’ Cause State Medicaid Programs to Erect High Hurdles?

And under the category of dog bites man, Texas AG Lawsuit Claims AstraZeneca Improperly Marketed Seroquel. Imagine, a drug company trying to sell its wares for unapproved uses. Shocking...

System Transformation

As much as I would like to ignore it, I feel I have to say something about Ebola. First, it is a tragedy of historic proportions for many of the African countries facing the epidemic. Second, people in the US are crazy and have a lot of other things they should be worrying about instead of worrying about an epidemic here. Think I'm being too harsh?  How about this case of a teacher who had only visited Dallas, had no contact with anyone remotely connected to treating the Ebola patient but was told to stay away from school for 21 days (School teacher in Strong put on 21-day leave over Ebola fears). To call that an overreaction is to give the term overreaction a bad name.

One of the best cases against this kind of behavior came from Sam Shepard of Fox News (yes, I said Fox News). Watch it for yourself:  Fox News' Shepard Smith destroys Ebola fear-mongering in 4 minutes.

What should you be doing instead of worrying about Ebola?  Going out and getting a flu shot:  Ruth Marcus: Actually, flu is the virus you should really be worrying about "If you are worried about contracting Ebola, I have two suggestions. First, stop. Second, get a flu shot."  And finally on this topic a look at Why travel bans will only make the Ebola epidemic worse.

OK, back to our regularly scheduled discussions...

In addition to worrying about the flu, enterovirus 68 may be of some concern.  That's the infection that has been going around the past few months and has unexpectedly resulted in several deaths. There is  now a new test:  Faster lab test will check for rare respiratory virus, which means a surge in confirmed cases is coming. So the stats will go up, but that won't mean the number of cases are increasing.

On the health IT front, a new way to get electronic health records to talk to each other has been recommended - if adopted it would be a great leap forward: EHR interoperability solution offered by key IT panels. Also close to home a Portland group announces ‘historic’ plan to become a health information destination. It's a great goal but I have to admit to being a bit skeptical. That said, I'd love them to be successful.

On a positive note: Breakthrough Replicates Human Brain Cells for Use in Alzheimer’s Research. This will allow for the first time the testing of drugs outside of human subjects with some expectation of being able to gauge their effectiveness. To this point, lab animals have been used before human trials and none of the substances effective in those lab animals has made the transition to being effective in people.

We talked placebos last week - but here's another story reminding us that Placebos Help. Just Ask This Health Economist.

And finally, A palliative care dilemma on the first day of the job. Sometimes figuring out the right answer is hard - a great reminder of why we need to have end-of-life conversations before we need to have end-of-life conversations.

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"

That Was The Week That Was - Issue 31

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

This week, we see the uninsured rate holding steady in the third quarter, HHS saying the Marketplace is ready, concern over the next open enrollment period and the tax season to follow. Also news that Medicare Part B premiums will remain flat, lots of other cost news, a startling study on placebos and surgery and a plea to go get your flu shot (highlighted by not one but two comic videos). Let's get started.

ACA: Polls/Opposition

Let's start with some good news: In U.S., Uninsured Rate Holds at 13.4% After the dramatic drop seen in the first and second quarters of this year, the rate held steady in the third quarter. To me, that's great news - one of the implications is that despite concerns, people are not dropping their coverage once enrolled. Although there are probably some dropping coverage while new people come on, the steady number says to me that for the most part "churn" is resulting from people moving between coverage (employer and individual, individual and Medicaid, etc), not from people dropping coverage.

Of course, that doesn't mean that public perceptions match the reality. "Attitudes toward the Affordable Care Act remain sharply divided along party lines. Democrats are much more likely than Republicans and independents to say the law has helped them, and Republicans are much more likely to say it has hurt them. Similar percentages of Americans from all three partisan groups say the law has had no effect." (More Still Say Health Law Has Hurt Instead of Helped Them)

And to drive that point home, opponents of the law are pulling out their old playbook and going with a previously failed strategy: GOP Senators Push For Lame Duck Shutdown Fight Over Obamacare.

ACA: Marketplaces

The closer we get to November 15th, the larger this category becomes. This week Secretary Burwell talked about the next open enrollment in positive terms: Burwell is bullish on Obamacare as open enrollment nears. But there be dragons ahead... Drew Altman takes a look at the Challenges for the Next Obamacare Open Enrollment while the Washington Post itemizes Five things we need to know before Obamacare enrollment starts again.

Meanwhile, HHS Says Obamacare’s New Website Will Work. For Real This Time. Among the improvements is that the "back" button now works - it may not seem like a big deal, but it makes a big difference when navigating the applications. And speaking of the application, reporters have seen it in action during a press event. It not only works but most people will fill out a shorter one this year as The White House has made applying for Obamacare a lot simpler.

But while we've seen the application, there is other behind the scenes work going on that will remain a mystery for now. The Wall Street Journal, referring to work between insurers and the Marketplace, reports that HealthCare.gov Testing to Be Confidential.

The experience will no doubt be improved, but it won't be perfect. "The site still won’t have any tools to allow consumers to see which doctors and hospitals are covered by individual insurance plans." (HealthCare.gov Still Suffers From Lack of Transparency). Those shopping for marketplace plans (and really for any plans) will need to check the insurance company website for network information, and if especially concerned about a specific provider, it wouldn't hurt to check with them directly.

ACA: Employers

Remember the sequester?  It's the gift that keeps on giving as Obamacare’s tax credits are shrinking for some small employers. Thanks, sequester.  Some small employers will see their credits reduced by 7%.

As some of you know, MeHAF has been sponsoring small business forums to help get the word out to them about their options (full disclosure, I'm one of the speakers). There was one earlier in Lewiston, yesterday in Portland (Small businesses in Maine weigh new insurance options under Affordable Care Act) and on October 21 there will be on in Bangor (you can go to enroll207.com for event information). While firms with fewer than 50 full-time equivalents have no obligation to provide coverage, there is a lot for them to consider and these forums are geared to helping them (and other employers) navigate the new landscape.

ACA: Other

You may have seen the headlines that  said 30,000 Lose Health Care Coverage at Walmart. Walmart has decided to eliminate health coverage to their part-time employees. Initially you may think that's a bad thing - but for most of those part-time workers, it's actually a positive. Many of them will be eligible for subsidies on the Marketplace, so they will be able to get better coverage for less money. Of course there will be some part-time workers who don't make enough to qualify for Marketplace subsidies (that's one of the reasons Medicaid expansion is so important), and it is unclear if when Walmart removes this expense from their bottom line if they will increase the compensation of the part-timers impacted. But those concerns don't seem to outweigh the number of individuals who will benefit. The moral of our story, beware knee-jerk reaction to headlines. The second moral of our story is our current system is way too complicated, but we'll save that for another day. (Tens of thousands of Walmart workers are about to lose their health insurance — and it's good news!  and Wal-Mart's Good News (Maybe) for Obamacare).

In an ironic juxtaposition, this week Walmart also announced it would be making insurance agents available in stores for a period overlapping with Medicare and Marketplace open-enrollment. No word on if the agents will sell marketplace plans or make customers aware of subsidies available, here's hoping they provide complete information (Wal-Mart adds in-store program to help customers compare insurance offerings).

Two studies look at drug usage among new Marketplace plans. Yes, as expected the new enrollees are older and sicker than those in employer plans. But the real question is are they older and sicker than what the plans expected?  That we don't know (yet) although the small rate increases this year seems to indicate they are not. (Health Law Drug Plans Are Given a Check-Up)

Also in health plan news, Health Plan Cancellations Are Coming, but for Relatively Few. There are those that will try and make a story out of this, but it shouldn't cause the stir it did last year, if for no other reason that the numbers will be much smaller. Last year when the administration said plans could be renewed even if they were not ACA compliant, they gave the state the option for continuing existing plans for up to three years. While some states (like CA) decided not to take them up on the offer instead saying that insurers could no longer offer non-compliant plans (unless they were grandfathered) here in Maine there will be no cancellations because the state did take the administrations offer and opted to allow those plans to continue.  

If you are enrolled in a plan, is it working like it's supposed to?  Not always as Kaiser discusses Hidden Costs For 'Fully Covered' Care Can Slam Patients' Wallets. Some of the problems with coverage for preventative services are simply insurers not following the rules, but others involve grey areas that require more clarity from CMS to get things working smoothly.

What about those who are not enrolled in plans this year?  Many of them will be eligible for waivers from the mandate. However, as we've talked about in the past, getting those waivers is not simple. Here is a thorough review of the issue: A maze to opt out of Obamacare individual mandate.

"Nina Olson, the IRS taxpayer advocate, said her team is “very worried that taxpayers will have returns coming in where they believe they’re covered by exemptions but they haven’t gone through the steps … particularly those needing” approval." 

"TurboTax estimates that less than 5 percent of exemption-eligible people have applied so far, suggesting a lack of education on how the process works. "

"The Centers for Medicare and Medicaid Services says it does not expect many people to apply for exemptions after Jan. 1, but many tax preparers predict the opposite. They say most uninsured individuals will come to their offices in early 2015 not knowing how to apply for exemptions — or even that they can opt out."

Here is another story on the topic: Health Law Waivers: Too Complicated To Claim?   This one also discusses an on-line tool being made available for free from TurboTax (TurboTax Exemption Check). It's a great concept but I have no firsthand experience as to how good the tool is.

On a related note, here is a Q&A from Kaiser on How Will Taxes Be Reconciled With Premium Subsidies?

While the "goal" of the ACA is to work towards universal coverage, we know that there are some people who will be left out, even if we achieve complete implementation. Some areas are working on those left out of the law as L.A. County offers $61-million health plan for those still uninsured "Los Angeles County will provide access to a primary care doctor for nearly 150,000 uninsured Los Angeles County residents, including many who are ineligible for Obamacare coverage because they lack legal immigration status."

And on a related note Los Angeles Health agency moving to skid row to aid homeless "Housing for Health's approach is based on studies showing that housing not only heals but also saves money. Emergency room visits and hospitalizations of homeless people dropped 77 % in the year after they were housed at a savings to the county of $32,000 a person, a 2013 study by the Economic Roundtable found."

Costs

We'll start off this week's cost discussion with some data. In light of last week's release of the Open Payments database, a survey looks at How Patients Will Use Physician Payment Data. Also more information on what is not yet included in the database: $1.1 Billion in Drug, Device Payments to Doctors Not Included in New Federal Database. And a look at how the database reflects other issues in our culture as the data shows Men Dominate List of Doctors Receiving Largest Payments From Drug Companies.

More data as CMS posts long-awaited Pioneer ACO quality and financial results. The Pioneer ACOs are the most ambitious of the various CMS ACO pilots. This data reveals that some organizations were very successful, but some not so much. The data also showed that most of the ACOs that dropped out of the Pioneer project did so after losing money in the first year.  Here is a look at one "Pioneer ACO" doing it right: The surprising Obamacare experiment that saved taxpayers $24 million last year .

Last year the Labor Dept. ruled that home care workers were subject to minimum wage laws (previously they had been categorized as companions so were not). However, succumbing to pressure from the states, Minimum Wage and Overtime Protections Are Delayed for Home-Care Workers. The pressure comes because many of these workers are paid by Medicaid and the increased costs need to be accounted for in state budgets. While there is no doubt the increased costs will strain the system, that is no excuse for not treating these critical workers fairly.

Sometimes we like shiny new things just because they are shiny and new, not because they are better than the old things. More evidence of this as "A study published today in the journal Obstetrics & Gynecology suggests that robot-assisted surgeries to remove ovaries or ovarian cysts were more expensive and had more complications than traditional minimally invasive surgeries."  ... "Until better standards are set in place, Wright said, “Patients need to understand the risks and benefits of different procedures… The newest, most high-tech thing that’s available isn’t necessarily the best.”" (Study: Robotic Surgery More Costly For Ovarian Problems)

In a similar vein,  Health officials tell medical technology group to 'prove it' "“We don't want to squelch innovation,” said Dr. Scott Josephs, national medical officer for the health insurance provider Cigna Corp. “But tell me what I'm getting for my healthcare costs. Show me that these new technologies are superior,” he told the audience during a session Wednesday morning."  ... "“The thing that's been missing from the model until now is the evidence,” said Diana Zuckerman, a researcher who has been critical of the Food and Drug Administration's procedures for approving and monitoring medical devices."    All I can add is a heartfelt Amen!

From the opposition, oops, I meant manufacturer side: Payment reform puts medical-device industry on the defensive  "Medical technology companies are warning that burgeoning pay-for-performance and risk-based reimbursement models will motivate providers to block access to clinically important innovations. ... Healthcare economists and quality experts, though, counter that the new models appropriately put the onus on manufacturers to prove their products are worth the cost."

For too long, medical device companies have released new products without any evidence that they are an improvement on what came before. Now they are complaining because people want to make sure there is "value" in the new technology?  Seems like a reasonable request to me.

In a positive (if incomplete) move, Massachusetts became the first state to require Price Tags On Health Care?  While it's a step in the right direction, note the caveats... they take up half the article.

In other cost control news, the savings impact of reference pricing was studied, and found to not have as much potential as some might hope: Study Finds Savings Low For Employers Capping Their Payments For Treatments.

Also see the Drug section below for additional cost related items.

Medicaid

In the latest study on this issue, the Urban Institute and RWJ found "that millions of women, minorities, young adults and those with low incomes are ineligible for health insurance assistance because their state opted not to expand Medicaid." Not that we needed more evidence that all states need to expand Medicaid, but here it is: In States That Don't Expand Medicaid, Who Gets New Coverage Assistance Under the ACA and Who Doesn't?) 

And for those who claim that being uninsured is better than being on Medicaid, more evidence that this is not the case: Medicaid, Often Criticized, Is Quite Popular With Its Customers

Medicare

Good news for Medicare beneficiaries as 2015 Medicare Part B premiums and deductibles to remain the same as last two years. This as we approach Medicare's open enrollment period that runs from October 15 to December 7. For my readers involved in the process the following article is unnecessary, for the rest of us it's a good primer (especially for those of us involved in that other open-enrollment period that overlaps this one): Beware of Shifting Options Within Medicare Plans. And for those enrolling in Medicare for the first time: If you find Medicare sign-up rules confusing, read this.

Also on the Medicare front, U.S. Revises Nursing Home Rating System. Improvements to the five star rating system should result in better data being used, in addition to other changes.

Drugs

We'll start with a warning: This Harvard researcher wants you to know that your supplements can kill you. Most don't realize how loosely these products are regulated. While the story focuses on a specific new additive which could be deadly to some (a scary enough thought) the problems with the industry are more broad based.

In a new survey, Morning Consult finds that Price Matters: Consumers Want Cheap, Generic Drugs. But at the same time, Officials Question the Rising Costs of Generic Drugs Some examples that led to the inquiry: "The price that hospitals and pharmacies pay for a bottle of 500 tablets of doxycycline, a decades-old antibiotic, rose to $1,849 in April, from $20 in October 2013. The price they pay for a bottle of pravastatin, a drug to lower cholesterol, rose to $196 from $27 in that same time."

But it's not just generics, '60 Minutes' Just Attacked High Drug Prices. Here's What You Should Know. 

There is no doubt this is a complicated issue. The other side of the coin, from a look at specialty drugs: ""Our study suggests that although specialty drugs often have higher costs than traditional drugs, they also tend to confer greater benefits and hence may still offer reasonable value for money," wrote the researchers at the Boston-based Center for Value and Risk in Health, which is funded in part by the pharmaceutical industry. (Why extremely expensive drugs are often worth the cost)

The problem is to figure out what a "reasonable" price is. As the 60 Minutes piece highlighted, one huge first step would be allowing Medicare, as the single largest payer of prescription drugs, to negotiate with drug manufactures on the price paid.

Here in Maine, in the spirit of our state motto, Dirigo (I lead) we are the first state in the nation to specifically allow importation of prescription drugs. As a result of the law, British pharmacy chain launches online drugstore for Maine consumers "By selling medications to Mainers at prices patients pay in Britain — which negotiates drug costs under the publicly funded National Health Service — Great British Drugstore can offer steep discounts, O’Brien said."  This story is getting national attention and was highlighted in the Wall Street Journal:  In Maine, the British are Coming… to Sell Prescription Medicines Online. As you'll see in the articles, the industry is not in favor of this development but so far has been unable to stop it. (Note that the negotiations by the National Health Service is exactly what Medicare is prohibited from doing.)

System Transformation

For those not familiar, the placebo effect is when a person's health improves after they think they are getting treated, even though nothing therapeutic was done to them. This article talks about the effect's presence in surgery (The Placebo Effect Doesn’t Apply Just to Pills) but it is an important reminder of how little we know about the care we get. It highlights the need for more research and more studies to understand how much of the treatment we receive is really having an impact.

On a related note, Can Big Data Tell Us What Clinical Trials Don’t? Clinical trials are expensive and take a long time. It's possible that many of the answers we seek are out there if we use the information in the right way. So the short answer is yes, mainly because we can't do all the clinical trials that are needed. While we must proceed cautiously, we still must proceed to mine big data.

Exercising the Mitchell rule (that's where I get to link to stories I'm quoted in), here is a piece from the Press Herald on virtual house calls: Doctors doing face-to-face house calls – over the Internet.

In a story that is getting a lot of attention, Terminally Ill 29-Year-Old Woman: Why I'm Choosing to Die on My Own Terms A sad reminder that end of life care, and choices, are not just for the elderly.

But the story highlights more than this one woman's brave decision: "We do not provide proper palliative care. As Atul Gawande relates in his beautiful new book Being Mortal, we do not reliably address people's deepest needs when they face life-ending or life-altering illnesses of many kinds. We can do a better job of relieving people's symptoms and protecting them from pain. We can protect families much more effectively against catastrophic medical expenses and hard caregiving burdens. We can work more effectively to ensure that every patient can make the most of their remaining days. We can more effectively promise that someone will die with dignity without the need to take precipitous measures while they still believe they can."  (This Woman Will Take Her Own Life November 1. Our Healthcare System Let Her Down.)

Speaking of Atul Gawande, did you hear the exciting news that he will be the keynote speaker at the 2015 Quality Counts Conference?  You can read his most recent column here where he talks about end of life care and asking the right questions: The Best Possible Day.

Enterovirus 68 is still in the news and still causing concern: After and Why the mysterious, new enterovirus outbreak is baffling experts.

But that is nothing compared to the Ebola coverage this week. Ebola: Does The Risk Justify The Intensity Of Coverage? The clear answer is no. At least not the way the coverage is being handled. We are focusing on an isolated incident her in the US instead of focusing on the impacted countries in Africa. For a primer, here are 9 questions you were too afraid to ask about Ebola. And here are the Diseases Americans should worry more about than Ebola, in one chart

That chart looks at a one week period, but if it had looked at a full year, or at a week during flu season, there would have been another standout candidate for what we should be worrying about instead: Ebola is Bad. But the Flu is Worse.

So we'll end this week with not one but two videos about going to get your flu shot - have you gotten yours yet?

• Stop watching this video and go get a flu shot (Sarah Kliff of Vox)
• Go and get your flu shot yo! (Z Dogg MD, the mind that brought you Doctor House of Cards)

All comments and suggestions are welcome; please let me know what you think. And as always, thanks for reading!

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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"