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!
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"
