Friday, October 3, 2014

That Was The Week That Was - Issue 30

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

Last year at this time I was freaking out. The marketplace had just "launched" and it was a disaster. What a difference a year makes. This week we'll start off looking at how the ACA is working in ways year-ago Mitchell would never have thought possible. Then for a dose of reality we'll look at some of the challenges we'll face with year two.

Another week, another court decision on the subsidies case, we'll take a look at that too along with network issues, Medicare penalizing hospitals, a new database on payments to providers and as always much, much more.

ACA: Polls/Opposition
Who would have thought when we were worried that a failed website would doom the implementation of the ACA that a year later we can look at 7 Charts That Prove Obamacare Is Working.

That said, as the second open-enrollment period approaches, there is still much work to do. While we shouldn't have the website problems we faced last year, there still be dragons ahead. In a new survey we're warned that Americans still confused by ObamaCare.

Here's a look at What Obamacare needs to do in year two  including the reminder that while it may be hard, we should not despair: "But Obamacare has the same advantage it had last year: it's still horrible to be uninsured. It also has a new advantage of a functional website. And in November, we'll start to learn whether that's enough to convince millions more uninsured Americans to buy the product that the Obama administration is selling." (For more detail on the next open-enrollment period, see the Marketplace section below.)

We're not the only ones in a reflective mood, Politico was as well... So if you're interested in a long, long read, here are 20 separate essays on what should come next, from repeal and replace to single payer: Obamacare 2.0 - The Affordable Care Act survived Year One. Fifteen health-care thinkers tell us how to fix—or reimagine—it for the long haul.

In addition to the approach of open-enrollment, there is the little matter of an election coming up as well. What happens to control of the Senate will have an impact on the ACA. While Republican control won't allow for the full repeal of the law (even the worst case scenarios do not envision Republicans gaining a veto proof majority) there is other damage that can be done. Here are two articles looking at the "what ifs": Congress Gets Its Hands on Insurer Incentives and How Republicans Could Use Reconciliation on Obamacare.

ACA: Court Cases
More activity on the subsidy case. This week a lower court ruled that in fact the subsidies could not be offered on the Federal Marketplace: Judge: Health care subsidies ‘abuse of discretion’. What does that mean?  The bottom line is not much. The ruling was immediately stayed by the judge to allow the appeal to be filed - so for now Oklahomans can continue to receive subsidies from the Feds. For an in depth review of the legal issues, here is Tim Jost's analysis: Implementing Health Reform: Judge Rules Against Premium Tax Credits In ACA Federal Exchanges.

Note this was only a district court - it will be appealed by the Feds to the 10th Circuit (which has a majority of democratic appointed justices, not that that is supposed to matter). Will this impact if and when the Supreme Court (SCOTUS) looks at the cases around this issue?  Basically, those who want SCOTUS to take the case early (those who oppose the subsidies in the Fed marketplace) predict this will cause SCOTUS to take the case sooner rather than later. Those who think the case is garbage think this result won't impact the: Obamacare Just Took a Hit in Court. Will SCOTUS Care?

ACA: Marketplaces
Keeping to our theme of remembering where we were a year ago, it's hard to believe that the new "CEO" of the marketplace said his goal is to have Raving Fans for Obamacare.

While I applaud the idea, it's definitely a stretch goal. But we do have a functioning website, which is a plus. That said, the next open enrollment period will have its own unique issues. First up, the auto-renewal process: Auto-Renewing Your Health Plan May Be Bad for You, and for Competition. There are potential landmines for those who accept the auto-renewal without updating their information, although many are planning to do so: In Second Year, Voters Less Interested In Exchange Insurance 
"Among those who have already purchased insurance on the exchanges, Morning Consult polling found that 43 percent plan to keep their insurance plan, 29 percent plan to shop for a new plan and 25 percent are undecided about what they’ll do."

Another issue is how to get those who have not yet signed up to do so. "Obama administration allies are weighing a focus on the loathsome individual mandate and the penalties that millions of Americans could face if they don’t get covered. It would be a calculated approach to prompt sign-ups, a task that the law’s supporters expect to be more difficult, or at least more complex, than in its coverage’s inaugural year." (Obamacare: New messaging hurdles ahead)

These issues and others are highlighted in this post looking ahead: Beware the sophomore slump.

Here in Maine, the Bureau of Insurance released information designed to help with the process: Bureau of Insurance Provides Guidance to Mainers Enrolling in or Renewing Health Insurance Plans as Open Enrollment Period Nears and the Kaiser Family Foundation released this report designed to help those working on enrollment: Taking Stock and Taking Steps: A Report from the Field after the First Year of Marketplace Consumer Assistance under the ACA.

ACA: Other
Remember the uproar about health plans being cancelled because they weren't ACA compliant?  Well it's time for Canceled Health Plans: Round Two as Insurers poised to cancel health plans that don’t comply with Affordable Care Act. As we get ready to go through this again, please keep in mind that the compliant plans people will be getting instead of their cancelled plans have better benefits. We expect less fuss this year for two reasons. First, this year it is a state option to allow non-compliant plans to continue or not (here in Maine they can continue), so there will be many fewer cancellations than there were last year. Second, many of those who were initially shocked at their plan cancellation last year went on to find better plans that ended up being cheaper once their subsidies were calculated, and those stories were widely circulated.  Of course there will be some fuss as opponents try and turn this into an issue, but it should not reach the levels of "outrage' we saw last year.

Speaking of outrage, thanks to another piece by Elisabeth Rosenthal (continuing her focus on health care costs) we have people asking when is a network not a network?  Unfortunately you can do all the right things, go where you should and think you are using the doctor you should and still face out-of-network charges (Costs Can Go Up Fast When E.R. Is in Network but the Doctors Are Not). This issue has been around since way before the ACA became law, but with the increasing tendency towards smaller networks and a greater cost differential in what is paid to out-of-network providers, it is becoming more of a problem.

Thanks to this increased focus, some are trying to figure out What should the law do about out-of-network ER docs? and ask the question Why Can’t States Do More to Protect Patients From Surprise Medical Bills?  As those pieces point out, yes the issue is complicated, but the time has come to address it head on (in the second piece you'll find a discussion of a New York law that could serve as a model).

We've passed the deadline for certain immigrants with paperwork issues to get their information to the Marketplace. But complaints have been filed alleging that HHS is kicking immigrants off Obamacare coverage without fair warning.

In other developments, Maine insurance co-operative accelerates plans to cover New Hampshire. Initially they were going to limit their entrance to just a few counties in New Hampsire, now they will be available throughout the state.

Costs
The big news in costs this week was the release of the Open Payments database You can now track the billions that drug companies pay doctors and hospitals  Why does this matter?  Doctors in the US who receive free meals or money from pharma companies are more than twice as likely to prescribe their medicines compared to those who receive no extra funding. (an old link but as relevant today as when it was published).

The coverage was exhaustive (and exhausting). From What We’re Learning About Drug Company Payments to Doctors to As Payments Database Debuts, Doctors Urge Caution to What to be Wary of in the Govt’s New Site Detailing Industry Money to Docs.

Unfortunately, in addition to the larger questions, the launch meant that Another Government Website Rollout That Is Found Wanting. You can judge for yourself here: Open Payments (Primary Source).

And finally, here is some of the Maine coverage New database reveals payments to Maine doctors by drug, device makers and What you should know about the new doctor payment data.

This week a couple of follow-ups to previous stories. First, in the continuing debate over the Dartmouth Health data and cost differences, another party heard from: Patient Health Doesn't Explain Cost Differences (coming down on the side that says the Atlas is showing real differences).

And second, unfortunately Proton Center Closure Doesn't Slow New Construction.

Need a reminder of how hard change is to implement?  Here is a story of a physician trying to do the right thing (by eliminating an order for unnecessary testing), but someone else thinks he made a mistake so does the wrong thing anyway: To reduce health costs, everyone needs to be on the same page.

And finally, on a positive note a study shows that Given Choice, Parents Pick Cheaper Medical Procedure for Children. Providing complete information is the key to having parents (and all consumers) make informed decisions.

Medicaid
A critical report this week from "the inspector general at the Department of Health and Human Services, says state standards for access to care vary widely and are rarely enforced." (Audit: Medicaid quality of care varies by state).

On a positive note, Texas and Florida Expand Medicaid – For Kids. Yes you read that correctly. Separate from the issues of Medicaid expansion for adults, many states were told to "fix" their eligibility requirements for children, and actually did so.

Medicare
The Marketplace open enrollment isn't the only one coming up, Medicare's is as well: Medicare Open Enrollment Is Fast Approaching -- Here's What We Know So Far. While not as complicated (or controversial) as the Marketplace open enrollment, there is still work to be done.

Also this week on the Medicare front "Medicare is fining a record number of hospitals – 2,610 – for having too many patients return within a month for additional treatments, federal records released Wednesday show. Even though the nation’s readmission rate is dropping, Medicare’s average fines will be higher..." ( Medicare Fines 2,610 Hospitals In Third Round Of Readmission Penalties.)

Drugs
In addition to the Sunshine database discussed above, there were other pharmaceutical developments this week. Starting with the positive, Roche Breast Cancer Drug Perjeta Appears to Greatly Extend Patients’ Lives ” Patients who received the drug — Perjeta, from the Swiss drug maker Roche — had a median survival time nearly 16 months longer than those in the control group."  The length of the improvement in survival times is unprecedented - usually new drugs add a few months at best.

Meanwhile, Genentech's distribution change for cancer drugs upsets hospitals. The manufacturer of three of the most widely used cancer drugs is now saying that they must be purchased from one of six select suppliers, no longer being available from drug wholesalers. This will drive up costs (and complexity of purchase) for hospitals. One sign of the blowback is that an operator of 130 hospitals, Ascension Health bars Genentech sales reps from its hospitals. Contrary to claims by Genentech it's hard to view this as anything but an attempt to wring more money out of the system.

And in other greedy drug company news, Novartis ordered to face U.S. lawsuit over doctor kickbacks.

System Transformation
The no cost-sharing preventative care provision of the ACA has focused attention on contraception. This week two pieces of information come out I had to share. First, Pediatrics group recommends IUDs, implants as best birth control for teen girls, then a new Study Bolsters a Call to Use Long-Acting Contraceptives while also showing that St. Louis gave teens free birth control, and they now have very low abortion rates.

More evidence of what we really already knew, that long-form birth control is more effective. It is also more expensive, making it even more important that the no cost-sharing provisions are available to everyone, regardless of the beliefs of their employer.

There is a deadly virus sweeping across the country. No, I'm not talking about Ebola (we'll get to that in a minute), I'm talking about a real cause for concern - Enterovirus 68 (Enterovirus 68: What Experts Are Learning). Four Deaths Are Linked to a Respiratory Illness and the First case of enterovirus confirmed in Maine. I share this not to incite panic (there is enough of that around Ebola) but to highlight that with all the recent talk about infectious diseases, we may not be talking about the right ones. Entovirus 68 often presents as a cold or flu, but in rare (but an increasing number of) cases, can involve serious complications.

You may have noticed that until now I have not written about Ebola - that's because as important and tragic a story as it is, it is outside the boundaries  of what I write about, namely US health  care and health policy. Despite a case being identified this week in Dallas, I still think this is the case. We in the US do not need to be worrying about getting Ebola (don't I give you enough else to worry about?). But don't just take my word for it: Voices: Even germaphobes don't need to fear Ebola ad Why There Won't Be an Ebola Outbreak in the United States and The 6 biggest myths about Ebola, debunked.

Want to worry about something?  Worry about the fact that Inequality is killing American babies. Our infant mortality rate is a national embarrassment  ”The difference is that in Finland and Austria, poor babies are nearly as likely to survive their first years as wealthy ones. In the U.S. - land of opportunity - that is starkly not the case..."

Also under the category of things we should be doing better, Why Don't We Treat Teeth Like the Rest of Our Bodies?  Before mental health parity, health care essentially stopped at the neck, our mouths, eyes and brains apparently weren't part of our bodies. We've added the brains portion, here's hoping we soon add the rest.

On the digital front, the Commonwealth Fund released two reports dealing with digital health: A Vision for Using Digital Health Technologies to Empower Consumers and Transform the U.S. Health Care System and Taking Digital Health to the Next Level.

Also, a growing realization that the way we've gone about creating EMRs (through competing products) may not make the most sense as Doctors Find Barriers to Sharing Digital Medical Records. In a reaction we can only hope increases, Epic Systems feeling heat over interoperability.

Several stories I'd like to highlight this week concerning our health:

And finally, for those of you that are enjoying the videos, this week The Garth Brooks low platelets parody video you can’t miss.


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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