Friday, May 2, 2014

That Was The Week That Was - Issue 8

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


Lots going on this week (although it feels like I say that most weeks). The final report for the now concluded first open-enrollment period was released, we also saw several new polls and much much more.  Let's dive in.
ACA: Enrollment Numbers
Over eight million sign-ups on healthcare.gov.  We had heard the number last week from the President, but now we have a lot more detail (Enrollment in the Health Insurance Marketplace totals over million people - announcement with link to tables).  Among the detail are breakout numbers for Maine, where we had 44,000 Mainers sign up for health insurance under Affordable Care Act (and being an equal opportunity blogger, here is the story from the Press Herald: Maine health enrollments beat expectations, officials say) .  That represents a 74% increase over the number from the end of February - by any measure a great accomplishment.  And while Maine lost the first place ranking in terms of percent of final target reached, the total still represented 192% of what the Feds originally expected for Maine (Enrollment by state with targets).
While there was a lot the enrollment report didn't tell us (What the enrollment numbers don’t tell us -full disclosure, I worked with Jackie on this piece so I'm biased when I say it does a good job looking at the larger picture) we did learn some new things (Four Things We Just Learned About Obamacare), some good such as the continued increase in Medicaid nationally, and some not so good such as Obamacare’s Hispanic enrollment is low, new HHS report shows.
(I can't mention the positive of the national Medicaid enrollment without pausing to lament yesterday's news that the legislature was unable to override the Governor's veto of Medicaid expansion here in Maine.  That means 70,000 Mainer's will continue to be denied access to health coverage until at least after the next election.)
For a deeper analysis of the report, we'll end this section with two dives into the report:  Tim Jost's blog post: Implementing Health Reform: A Summary Health Insurance Marketplace Enrollment Report and Ezra Klein's Seven things we now know about Obamcare enrollment.
ACA Polls/Politics
All these polls tell a similar story - despite the fact that many people know the law has signed up eight million people through the marketplaces, they think the implementation was a failure.  The majority also still oppose the law while at the same time they  don't want to see it repealed.
Previously I had been attributing the continued poor public perception to the fact that all the good news was more recent and those perceptions had not caught up to the reality.  Unfortunately, Ezra Klein has set me straight (Americans believe two things about Obamacare enrollment that can’t both be true). He talks about "belief echoes", after receiving negative information on a topic, even if later that information is corrected, the negative feelings persist.  That seems to be in play with perceptions of the laws implementation.  This complicates the communications strategy going forward.  (Not that there is a single communications strategy among supporters of the law, and not that the previous communication work has been as successful as we might have hoped.)
With the concept of belief echoes in mind, it's easier to understand the GOP report released this week regarding estimates of how many of those selecting a plan have paid their premium (GOP: Health signups lagging).  While the flaws in the report were quickly pointed out, the damage had already been done.  The report said that only 67% of those selecting a plan had paid their premium.  Among the problems with that number, it was calculated using as a base all the people who had selected a plan, including the millions who had done so in March and April and whose premium was not yet due.  Not to mention the fact that insurers themselves had been quoting an 80%-90% rate of people paying (Obamacare Is Getting the Benghazi Treatment, Courtesy of House Republicans). 
The irony that the key foundations of the ACA used to be conservative principles seems lost on some.  An alternative to the ACA was put forward by Scott Brown (ex MA Senator who in the best carpetbagger tradition is now running for Senate in NH).  His plan, minus the name looks very much like the ACA.  One of the reasons we've not seen a national "replace" plan put forward by the law's opponents is just this dilemma - it would inevitably look like the current law:  The Republican replacement for Obamacare is Fauxbamacare.
In case you were already tired of all the drama leading up to the 2014 elections, you can skip ahead as Health care wonks turn to 2016.  Here in Maine if you are still thinking about this year's elections, here is a  Interesting look at the impact of the ACA on our (Maine's) gubernatorial race.  Although not a perfect piece, it sets up some of the lines of disagreement we'll be hearing more about Obamacare gives voters a clash of candidates .
The nomination of Sylvia Burwell as the new Secretary of HHS was expected to be a battle.  It's now looking like her nomination will be confirmed (Sylvia Mathews Burwell: The Obamacare war that wasn't), although the hearings will still be a bit of a circus (Republicans to push anti-Obamacare message in Senate hearings).
And finally with respect to the laws opponents, offered for your amusement is this report on a group that is trying to convince insurance companies not to take Federal dollars: The Least Promising Anti-Obamacare Campaign.
ACA: Premiums/Costs
When insurers set rates they usually have the previous year's plan experience on which to base the new rates.  This year the Affordable Care Act plans pose actuarial and rate challenges for insurers.  That said, this week Insurers sound pretty happy about Obamacare.  The final age breakdown is looking like what they expected (remember, this was always the key question, not if the age breakdown mirrored the population measures) and people are paying their premiums.  While early on some insurers were nervous, the most outspoken  one has now reevaluated (Major Obamacare insurer backs away from double-digit rate hike prediction).
There will be 51 different stories to this year's rate increases - one for each state (and DC), because in spite of changes made by the law, each state is still it's own market.  So while overall U.S. says Obamacare enrollment points to stable costs we can be sure there will be a few states that are outliers and their high rate increases will be painted as a national calamity.
The GDP report for the first quarter was released this week and it showed Health Spending Gains as Obamacare Patients Use the Plans.  Total spending is based on a combination of unit cost and volume - the good news about the increased spending is that it seemed to be the result of volume.  If that turns out to be true, it represents a very expected development (That Spike in Health Care Spending May Be Here, Right on Schedule: Cue premature, unnecessary panic).  People who were without coverage for a long period of time will have pent-up demand for services, so it is to be expected that there would be a spike usage of services as they gain coverage.  If anything, we can view this as a positive development - people are no longer postponing the care they need.
ACA: Other
The New York Times had an in-depth piece Envisioning the End of Employer-Provided Health Plans.  While it is well done it's not perfect and was a bit fuzzy on some crucial details.  Let's take a look at the issue. 
To start out you have to understand that it is not possible to overestimate the importance of the tax advantage employer-sponsored plans have over the individual market.  The deduction costs the Federal Government $250 billion dollars a year.   When the ACA was being drafted, expanding the tax deduction of premiums to individual policies was discussed, but it was just too expensive.  As long as that duality remains, it will be very hard for employers to truly leave the market.
Note that there is a difference between the move to a defined contribution health strategy and leaving the employer market.  It is possible for the way employer-sponsored coverage is provided to change drastically while still preserving the current tax advantages - but that does NOT include the ACA marketplaces (and does NOT include employees being able to access the individual subsidies), instead it includes private marketplaces (or exchanges).  This shift would mirror what we saw happen to pensions with the switch to 401(k) plans.  Instead of a defined benefit, a set dollar amount pension you would receive once you retire, the employer provided a defined contribution plan - they set the amount they contribute, the amount you receive when you retire depends on how the account does in the meantime.  For health benefits, the employer would set an amount they would contribute and send the employee to a private marketplace - the employee would purchase whatever plan they wanted and be responsible for the difference in cost over what the employer contributed.  With a private marketplace this could be done in a way that the employee's contribution is still paid with pretax dollars.  So with this in mind you can see that  talk of the death of employer-sponsored coverage has been greatly exaggerated.
While healthcare.gov underwent a remarkable recovery after its initial launch, much work on the site remains to be done.  A lot of the back-office functionality where it pays the insurance companies subsidies is still a semi-manual process and needs to be fixed (Behind the scenes, much of HealthCare.gov is still under construction).  With the contract for administering the website expiring, the Administration Begins Search for New Contractors to Run Health Care Site. 
Some front-office functions still need work too, among them are the availability of provider network and formulary information.  A recent review found Health exchanges’ drug coverage confusing highlighting the need for a technical fix so individuals can check on benefits during the process.
The question "is a state better off running its own Marketplace" may be seen as a toss-up so far.  Some states (CT) were very successful, some (OR) were outright disasters and most fell somewhere in-between.  Initially some thought that it would be more efficient to just have one Federal Marketplace (that is how the initial House version of the ACA was written) while some thought the States should have the control.  With the jury is still out, we note that although there is still funding for states to build their own Marketplaces, Most States To Rely On Federal Website For 2015 Enrollment.
We saw another "fix" pass the House this week.  Some said the House passes bipartisan fix to health law the truth is that it was not quite bipartisan.  There is widespread agreement on the need for a fix under the health law for U.S.-written expatriate plans that can be sold to Americans working overseas and foreigners working here or elsewhere. The original bill was supported by the White House to fix this issue but they ended up objecting to the final version due to loophole that would allow permanent residents to purchase these non-compliant plans indefinitely.
Drugs
The cost of drugs is always an issue.  One of the stories we've been told is that the exorbitant price of brand name drugs is because of the need to recoup the development costs both on the drug produced and on all the drugs that never make it out of the pipeline.  That reasoning is coming more and more into question due to the fact that the Federal Government ends up paying for a lot of the basic science leading to these drugs and that many of these drugs are simply reformulations or packaging of existing products (Why patients cannot afford to have asthma or gout, For Drugs That Save Lives, a Steep Cost).
Last week saw a transfer of units among three major pharmaceutical firms, this week saw what was almost, and still could be, one of the largest mergers in history with Pfizer Proposes a Marriage With AstraZeneca, Easing Taxes in a Move to Britain.  Doesn't sound like improved science is the motivation for the deal, and while AstraZeneca Snubs Pfizer Approach That U.K. Won’t Block, the deal is by no means dead, so stay tuned.
In addition to cost, we also need to keep our eye on the quality and safety of prescription medications.  150 Americans have die annually and tens of thousands have gone to the emergency room each year due to overdoses  of Tylenol (Here's why you shouldn't take extra-strength Tylenol).  As you can read in the article, while the FDA is taking steps to limit intake through prescription drugs, not enough is being done regarding the over-the-counter formulations.
The FDA fails in removing other harmful "drugs" from stores (Why Dangerous Supplements Linger on Store Shelves).  And on the topic of supplements, remember that just because something is "natural" does not mean it's safe (A few thought-provoking questions about essential oils).
Also this week the World Health Organization released a report on the dangers of antibiotics:  Planet headed toward ‘post-antibiotic era’ when treatments don’t work: WHO.
Costs
Some great reminders on where the money to pay for our health care system really comes from (spoiler alert, it's not really the free market system you thought it was) Who really pays for health care? It might surprise you.  This also gets at one of my underlying principles when we discuss health care - ultimately it's you and me that are paying.   It may be funneled through taxes or reduced wages, but ultimately it comes out of our pockets.
Maryland has long been a leader in attempts to control health care spending.  That leadership continues with its most recent attempts to put hospitals and health care systems on a budget.  Success here could see other states give these methods a try (The Maryland approach to controlling health costs). 
A reminder from the CDC that Hundreds of thousands of Americans die unnecessarily every year.  Why is this article in the costs section?  Because the system expends resources on these unnecessary deaths (and the conditions that lead to them).  A major factor in four of the five leading causes of death is tobacco - and while we may be winning the fight against smoking, we can see from these numbers that it's far from over.  The four conditions related to tobacco are: heart disease, cancer, lung disease and stroke with the fifth leading cause being  unintentional injuries (CDC: 5 things cause two-thirds of U.S. deaths).
System Reform
Before ending with our laundry list of system reform articles, I'd like to pause and take a step back to remember why we're doing all this.  Health care isn't a goal in and of itself, it's one means to ensuring our quality of life. Sometimes that actually means saying no to health care (Quality of life: We say it, but do we mean it?) and knowing when to have difficult conversations (Speaking up about hospice is not a betrayal of our family members).
And finally, this week's laundry list of articles talking about the transformation taking place around us.


All comments and suggestions are welcome; please let me know what you think.  And as always, thanks for reading!
Funded by support from the Maine Health Access Foundation

*The title is a tribute to the BBC show, the NBC show and the amazing Tom Lehrer album "That Was The Year That Was"
Posted by at

Friday, April 25, 2014

That Was The Week That Was - Issue 7

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


This week I've introduced section heading to help make the newsletter more readable - let me know what you think.

ACA: Impact

With no new numbers released this week the media took a step back to try and gauge some of the impact of the law.  We discussed last week the extent that the eight million number is only one piece of the puzzle.  Politico followed suit and provided this analysis: Beyond 8 million: Obamacare math.   We're also reminded that this is just the beginning, or as some would say, it's a marathon, not a sprint.  While millions gained coverage, many made the decision to continue to go without.  Here is a snapshot of four people who made that decision: Looking at Costs and Risks, Many Skip Health Insurance. 

ACA: Plan Cancellations (?)

Note the question mark in the title above, one of the talking points of opponents to the law is that while some people are enrolling in coverage, many (and some say many more) are losing their coverage.  New analysis out this week shows the fallacy of that statement.   The study (Health Affairs Web First: October 2013′s Insurance Cancellation Firestorm In Context) looks at the volatility of the individual market before the law took effect.  It confirms what many of us already knew - the amount of churn is high to the point where many more people drop their coverage each year than received cancellation notices  (Study questions Obamacare impact on canceled plans). 

The rhetoric around plan cancellations has gotten so divorced from reality that the Washington Post Fact Checker gave out a rare four Pinocchios (or in other words, liar liar pants on fire!) to Rep. Tim Huelskamp of Kansas who keeps saying that the ACA has resulted in an increase in the number of uninsured (The bogus claim that Obamacare has boosted the number of uninsured).

Let's also remember why plans were cancelled - it was because they provided inadequate coverage and so were not true insurance. Additionally, there is another whole class of plans called "fixed benefit" plans that have previously been judged to not meet the requirements of the mandate - so if someone bought one of these policies they still needed to buy an ACA compliant plan.  The Feds are now contemplating expanding that ruling to say that someone may not purchase one of these plans unless they show proof of ACA compliant coverage.  This change would very much be in the consumers' best interests.  These plans only supply a fixed amount of money per day when certain conditions are met, so while the amount may help towards an individual's out of pocket costs they are totally inadequate to pay the full cost of treatment for most conditions.  So prepare for more headlines along the lines of  If you like your health plan, you might lose it. Again.

ACA: Politics

The New York Times in conjunction with the Kaiser Family Foundation released poll results for four Southern states (POLLS IN FOUR SOUTHERN STATES: April 8-15, 2014).  These polls while especially relevant to the Senate races in the  four states, but they also indicate a possible shift in perceptions regarding the law.  While Southerners Don’t Like Obamacare. They Also Don’t Want to Repeal It.  These results and others seem to indicate that Obamacare's Success Is Destroying the GOP's Midterm Strategy.

But that is just once perspective.  Opposition is still strong (Obamacare Bashing or Bust, 38 GOP lawmakers join Ron Johnson’s Obamacare lawsuit) even as Democratic Candidates Grow More Vocal in Supporting Health Law (and Landrieu: I’ll put GOP foe on defensive on health care).

As you can see, there are as many different perspectives on the politics of the situation as there are political pundits.  That's how you can get dueling headlines like: Here’s why Obamacare is still a major problem for Democrats and Here’s Why Obamacare Will Help Democrats and Hurt Republicans.

My bottom line is we don't yet know what's going to happen in November, the landscape and resulting public are changing to fast and in too unpredictable a manor.

Costs

When we talk about the ACA, although there is much more to the law, for the most part we are talking about increasing access to care.  But long term, the cost of care will determine if we can afford to provide access to everyone.  Before we dive in to this week's developments regarding cost, a bit of a reminder about two its components.  Here in the US we spend a greater percentage of our GDP on care for the same (or worse) outcomes as other nations.  This is principally due to the prices we pay for that care, they are much higher in this country than in others.   So some of our efforts need to be focused on controlling the existing prices.  We are also facing, along with the rest of the world, disproportionate  increases in the cost of care.  Often referred to as medical inflation or trend, historically it has outpaced overall inflation resulting in health care taking an ever increasing share of our personal and national income. So we also need to be focusing on the rate of increase. 

Recently we had been seeing a historic slowing of the health care trend.  While some of that slowing may have been the result of initiatives within the law (such as ACOs), much of it was due to the great recession.  Unfortunately as the economy picks back up, we are seeing a renewed acceleration in costs (Health Care Spending’s Recent Surge Stirs Unease, Acceleration Is Forecast for Spending on Health, Return Of The Repressed: Spending Growth Is Back, But What To Do?).

However, all the news is not gloomy.  The CBO Finds Health Reform's Medicaid Expansion Is an Even Better Deal for States.  Mostly as a result of refining their estimates on the size of the "woodwork effect" (people who were previously eligible but were not enrolled now enrolling) the overall budget impact on Medicaid has been reduced.

Costs and the Drug Industry

Turning to the cost of prescription drugs, one nuance to the conversation is the impact of new treatments to our costs.  Sometimes there is a clear benefit to the new treatment (or drug) as is the case of the new treatment for Hepatitis C.  However, what is charged for that improved treatment can be problematic.  In this case, because the firm that created the drug was purchased before its release, we can do a calculation on what the return on investment is for the drug.  Whatever your feelings on the private markets role in our system, I think we can agree that a 2500% ROI is outrageous (America's Broken Health Care System: The Role of Drug, Device Manufacturers).  None the less the Costly Hepatitis C Pill Shreds Drug Industry Sales Record and has resulted in soaring revenue for the company (Gilead Revenue Soars on Hepatitis C Drug).

We see that the industry continues to work to preserve their profits (Some top Medicare beneficiaries spend heavily to lobby) while the question of how we deal with this continues to be debated (RAND: Medicare Should Weigh Cost In Coverage Decisions).

In other pharmacy industry news, we had FDA Advisers Vote Against Approving New Opioid Painkiller (because they saw no increased benefit but did see an increased risk of abuse).  we also had an Alternative to Pap Test Is Approved by F.D.A., even though it is more expensive and may result in more false positives.  (Perhaps the result of the lobbying referenced above.)

And finally, we had three gigantic firms shift around assets in a blockbuster deal Glaxo, Novartis, Eli Lilly in 'major 3-part' deal, Novartis reshapes business with GSK, Lilly deals).  Not sure how the patient benefits from this but clearly the shareholders will.

Medicaid

While here in Maine we have not yet expanded the eligibility requirements for Medicaid, national developments that can impact our program move forward (Basic Health Program. The Affordable Care Act offers states another option besides Medicaid and the exchanges for health coverage for low-income residents., Connected Health Opportunities For Medicaid’s Most Vulnerable Patients)

Separate from ACA reforms, we're also seeing some progress on how Medicaid interacts with the disabled: How Medicaid forces the disabled to be poor (but some bipartisan help is on the way).

System Transformation

Health Care is a business.  We know that in the current system providers need to keep that in mind in order to keep the doors open (With Medical Debts Rising, Doctors Are More Aggressive About Payments, You're on the clock: Doctors rush patients out the door), but don't worry,  Doctors still make good money.

Finally, this week's laundry list of articles talking about the transformation taking place around us.  The analogy renovating the car while hurtling down the highway seems to apply...


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"
Posted by at

Friday, April 18, 2014

That Was The Week That Was - Issue 6

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

Never underestimate the American public's ability to procrastinate!  The President announce on Thursday (4/18) that as of the end of the extended open enrollment period, over 8 million people had selected a plan on the Marketplaces (Enrollments Exceed Obama’s Target for Health Care Act).   Coupled with several other sets of numbers this week that I'll discuss below, the President was jubilant during the White House press briefing where he announced the new number (Obama on health care law: 'This thing is working').

When the Federal Marketplace launched in October (or failed to launch) no one thought we would get here.  Even before the technical issues, initial projections did not go this high.  But as pointed out by many yesterday, in retrospect we shouldn't be surprised by the late surge.  At the end of the day, Obamacare succeeded for one simple reason: it's horrible to be uninsured.   That's the simple truth that many pundits (who probably have never been uninsured a day in their lives) can't seem to understand.  Enrolling in insurance might be hard, but there is a tremendous carrot at the end of the process - you are covered.

And lest we forget this is much more than those using the marketplace.  The HHS fact sheet released in conjunction with the announcement (FACT SHEET: Affordable Care Act by the Numbers) reminded us that "Up to 129 million Americans with pre-existing conditions – including up to 17 million children – no longer have to worry about being denied health coverage or charged higher premiums because of their health status.  71 million Americans with private insurance have gained coverage for at least one free preventive health care service such as mammograms, birth control, or immunizations in 2011 and 2012. and more.

For a full review of the announcement you can read America's Sherpa through the ACA landscape, Tim Jost, in his Health Affairs blog post:  Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers 

If there was  a disappointment yesterday it was that we did not get a full enrollment report, only top-line numbers.  While we wait for the formal HHS report, I was able to find one state specific projection that said Maine's Marketplace total would end up at 52,000 (Maine Projections: 52,000!)!

Before we leave yesterday's announcement and get to the rest of the week's news, let's pause to note that The Other Important Number In The President's Obamacare Briefing: 24.  That's the number of states that have not participated in the Medicaid expansion.  So while the law is benefiting many, some are still being left out.  Here in Maine the battle continues with one more try to get past the Governor (Final-hours push for Maine Medicaid expansion appears headed for another LePage veto).

In some ways yesterday's announcement was the icing on the cake (or CAHC considering all the great work they've been doing).  Let's start with the question of how many people are actually newly insured.  That's been one of the big criticisms of the HHS releases to date - they don't say how many people are newly insured.  Well Gallup has come galloping to the rescue (sorry, couldn't resist).

New poll results released this week said that: Obamacare effects are bigger than expected, poll finds:  New Gallup survey data suggest that about 12 million previously uninsured Americans have gained coverage since the fall.

Additionally, the poll notes that not all the newly insured are getting coverage through the marketplace: Newly Insured in 2014 Represent About 4% of U.S. Adults:  Half of newly insured obtained health insurance through exchanges.  Remember, the mandate is also working to encourage people to enroll in their employer-sponsored plan and many who had not previously done so are doing so now.

Unfortunately but not surprisingly, the poll also showed that Uninsured Rate Drops More in States Embracing Health Law.  This is not a single national implementation, this is 51 state-by-state implementations (plus DC).  And these results show it matters as to if the state has built their own Marketplace and if they are participating in the Medicaid expansion.

Other good news came this week from the Congressional Budget Office (CBO).  They updated their cost estimates for implementing the law showing that it will cost much less than originally estimated (Obamacare's price tag just got cut by $104 billion) due to lower than expected premiums (Lower premiums (yes, really) drive down Obamacare’s expected costs, CBO says).  You can read the actual report here:  Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014 (CBO direct link).

And speaking of premiums, New data signal smaller jump in health care costs:
" Statisticians working with insurers to project next year's insurance premium rates say they expect to see an average increase of about 7%, well below the feared double-digit increases making recent headlines.  "The double-rate increases we've been hearing are probably exaggerated," says Dave Axene, a fellow with the Society of Actuaries, adding that there would be wide variation across the country."

More good news came from the United Healthcare.  They indicated that they would be participating in more Marketplaces for the next enrollment season (The nation’s largest insurer thinks Obamacare exchanges are doing just fine) in spite of having some profit problems due to the new Hepatitis C drug (Biggest Insurer Shocked With Hepatitis C Costs). 

Of course a week can't go by without some controversy, and the Census Bureau was able to provide us one for this week.  They announced that they will be changing the way they collect information on how many people are insured.  This caused an immediate uproar by opponents of the law who thought it was a conspiracy to mask how ineffective the ACA actually was.  The problem with that theory is that the changes are being made to how the numbers for 2013 are calculated - note that is before the access provisions of the law took effect so there will be a new baseline established before the law's impact is measured.   (Don't freak out about the changes to the Census yet.)

We learned last week that Secretary Sebelius  was resigning and Sylvia Burwell was nominated to take her place.  It was pointed out this week that although she was approved unanimously by the Senate for her current position, don't expect her confirmation hearings for HHS to go as smoothly:  Burwell hearings to be debate over health care, Obama's new health secretary nominee draws early Republican fire.  There is no question she has a lot to do when she gets there, but this week's numbers should help make the job a little easier (Burwell's top five challenges at HHS).

While The right can’t admit that Obamacare is working and Obama tells Democrats: Defend my law, we might finally be seeing perceptions of the American public catching up with the reality of the law's successes (Americans increasingly prefer Democrats on healthcare: Reuters/Ipsos poll .

We can't forget what this is all about, a Mainer wrote about her journey to help us remember: Saved by Obamacare .  And a doctor wrote about how the system as it currently exists sometimes creates incentives that increase risks (A patient nearly died to save him $1110).  On a larger scale, new numbers remind us that Our health spending problem is all about prices.

On the transparency front, New medical data could allow comparison shopping.  We know that Price transparency stinks in health care. Here’s how the industry wants to change that.  The new report (which can be read here) Price Transparency in Health Care: Report from the HFMA Price Transparency Task Force is the first industry blueprint for how they want to address the problem.

Before we end with our laundry list of system transformation developments, let's focus on diabetes for a moment.  A new study shows that we are making real progress in getting them appropriate treatment (For Diabetics, Health Risks Fall Sharply) and the efforts will continue for the newly insured (With new health law, insurers target diabetics).  Good news all around - getting the treatment of chronic conditions under control is crucial to controlling costs.

Some additional system transformation stories I found interesting this week:


And finally, I'll end which long-term could be the most important story of the week.  Using existing data to do outcomes research - the holy grail of "big data" in health care, and one of the unsung reasons for moving to EMRs, just got a step closer:  Scientists embark on unprecedented effort to connect millions of patient medical records

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"
Posted by at

Friday, April 11, 2014

That Was The Week That Was - Issue 5

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

7.5 million and counting, that's where we stand with respect to those choosing a plan through the Marketplace - just wanted to get that out of the way before we dive in to this week's news.  Soon to be ex-Secretary of HHS Katherine Sebelius gave the updated number on Capitol Hill yesterday.  If you're wondering when we'll see the March enrollment report, if the past is any indication HHS will release it between the 11th and 14th.  That said there is no official word on if they will do so again or wait until the end of April when they can include the enrollments through the extension deadline of April 15th (the report would then include the 7.5 million and more).   

For those confused by the "soon to be ex" in front of Sebelius above, it's because last night we learned that she will be resigning as Secretary of HHS and current  Office of Management and Budget (OMB) chief Sylvia Burwell will be nominated to take her place.

This is big news, but in the end not very surprising.  If there was ever a time for her to make a graceful exit, this is it, after the successful end of the open-enrollment period and before the start to this year's election season.  There will be (and has already been) much written about her legacy (Health Secretary Resigns After Woes of HealthCare.gov, Website fiasco will taint Kathleen Sebelius’ legacy but I look at it this way.  She was a great Insurance Commissioner and then Governor in Kansas and has done a lot of good at HHS.  With our 20-20 hindsight we now know that she was not the right person to oversee the creation of the website, but the botched rollout should not be the only way she is remembered (The Sebelius Legacy: One Epic Tech Failure, Millions of Newly Insured Americans, Republicans pile on at news of Sebelius’s exit).

In fact, it can be said that her resignation now is a positive sign, in the words of Ezra Klein: Kathleen Sebelius is resigning because Obamacare has won.  (Yes, our old friends Ezra and Sarah are back, their new site vox.com is now live - and no, I don't believe there is a wonk bubble.)

The President's choice to replace her, Sylvia Burwell, is an impressive one.  In addition to being the current head of OMB she served in the White House during all eight years of the Clinton presidency in various roles, is a graduate of Harvard and a Rhodes Scholar.  Additionally, in her work both during the shut-down and during the budget deal to follow, she showed she can work with legislators on both sides of the aisle.

In fact, one of the first reactions to her nomination came from Senator McCain who tweeted:  “Sylvia Burwell is an excellent choice to be the next HHS Secretary”.  You can read more about her background here Meet the nominee to lead HHS and here Sylvia Mathews Burwell: Six things to know about the new White House budget director (March 2013).  But that doesn't mean the opponents of the ACA won't be playing this event for all it's worth: Sebelius exit opens new Obamacare front.

Even before this news hit on Thursday night, there was a lot to talk about this week.  Rand issued a new report regarding the previously uninsured who are now have health coverage:

"The survey, which comes with some caveats, finds that of the previously uninsured who gained new coverage, 7.2 million were covered by employer plans, 3.6 million were covered by Medicaid and 1.4 million signed up through the Obamacare exchanges. In all, employer coverage increased by 8.2 million since September, Rand said."    (Forget about Obamacare exchanges. Employer coverage is booming, survey finds)

While many were surprised by these numbers, we shouldn't have been.  Remember, the greatest number of people in this country with health insurance get it from their employer. One of the benefits of the mandate is it encourages more people to accept that offer from their employers. These numbers for the first time show the extent of that increase (Should we have expected this week’s big surprise on employer health insurance?,  The best evidence we have that Obamacare is working).  You can read the primary source and link to the actual survey here: Survey Estimates Net Gain of 9.3 Million American Adults with Health Insurance.

There were other numbers released this week as well, a Gallop poll showed the number of uninsured continues to decline (note that these do not even reflect the March enrollment surge  Another Day, Another Sign That Obamacare Is Working).  Other number released showed that as expected, it was the sicklier individuals who signed up first (Study Finds Sicklier Enrollees in Earliest Stage of Health Law) which can also be understood to be a positive since these people needed care (More Evidence Obamacare Is Getting Insurance To People Who Need It).

As part of the doc fix legislation discussed last week, there was an ACA fix included to eliminate the requirement that employer plans adhere to a different standard re out-of-pocket costs than individual plans.  To me, this represented the first substantive adjustment to the law supported by both proponents and opponents of the ACA (GOP seeks coverage choices in health law they hate).  For a while it looked like we would see another example - this time as a standalone bill (House to pass new, bipartisan ObamaCare tweak) with an adjustment to requirements for ex-pats.  However, the compromise wording ended up failing to win the expected bipartisan support and did not pass the House (House rejects expatriate Obamacare bill).

For those keeping track, mid-April was when we were going to finally see the Republicans' alternative to the ACA, alas that is not to be:  House GOP: We'll Have That Obamacare Alternative Soon! Really!.  In perhaps one of the most revealing quotes on this topic, you had a Republican staffer admitting what proponents of the law have been saying all along - the ACA is the most conservative friendly way to accomplish the goal of universal coverage:

"If you want to say the further and further this gets down the road, the harder and harder it gets to repeal, that's absolutely true. As far as repeal and replace goes, the problem with replace is that if you really want people to have these new benefits, it looks a hell of a lot like the Affordable Care Act. ... To make something like that work, you have to move in the direction of the ACA. You have to have a participating mechanism, you have to have a mechanism to fund it, you have to have a mechanism to fix parts of the market."  (The Right Searches for Obamacare Replacement, Finds Obamacare)

Of course there are those who don't want a conservative friendly solution to the issue and are trying a different tact - you can find some of them in Vermont (Forget Obamacare:  Vermont wants to bring single payer to America).

This week also saw the historical release of physician level Medicare claims data.  This is the first time that physician level data is available to the public.  There has been a tremendous amount written about this (a sample of links are below) but here is my take:  For all its shortcomings this data is an important part of the process of reforming our system.  The data is not perfect and you need to take some time to understand it, but it will provide a great resource for analysts and advocates to better understand the state of our system.  While there is opportunity for individuals to look up their own providers (EASY LOOK-UP:  How Much Your Doctor Received From Medicare) the power of the data will be in what it reveals about the system (Nobody Blames Doctors for High Medical Costs. That's About to Change, Disclosing Medicare payment data could be a boon for the nation).

For those who want to dig deeper...

First the basics: Everything you need to know about today’s unprecedented Medicare pricing data dump
Next some of the information gleaned so far:  Cost of drugs used by Medicare doctors can vary greatly by region, analysis finds, Sliver of Medicare Doctors Get Big Share of Payouts, Want to see how problematic Medicare pricing is? Look to ophthalmology  The top 10 Medicare billers explain why they charged $121M in one year, How does one doctor earn $21 million from Medicare?.  No, I don't expect most of you to click on all those links, but I want to make the point that there is a lot to be learned from the data in spite of its limitations.

Giving equal time: The Medicare Data’s Pitfalls, Doctors react to release of Medicare billing records and Political Ties of Top Billers for Medicare.

For those looking for the local take, Jackie Farwell did a deep dive into Maine specific data: Long-secret Medicare data reveal payments to Maine doctors.

And finally, if you really want the details, here's where you can get the data yourself: THE DATA: Medicare Provider Utilization and Payment Data: Physician and Other Supplier.

Also on the Medicare front, the Administration released the new Medicare Advantage (MA) rates.  I'm sad to report that bowing to political pressure, the new rates were not as low as indicated in the preliminary guidance issued earlier.  To recap, MA is a program that allows seniors to enroll in a private insurance company plan instead of traditional Medicare.  This was originally introduced because the private market said they could provide the benefits cheaper than the traditional plan.  That didn't happen.  Instead, MA plans now get more for each enrollee than the government pays for traditional Medicare.  The ACA said that's not fair to the over 70% of enrollees who are not in an MA plan, if the private plans want to play, they should get the same amount as everyone else.

That was the plan, but there was a lot of pressure from both sides of the aisle (Here’s the next part of Obamacare that has Democrats worried about November) to keep the MA plans happy and the enrollees unaffected by any changes.  As a result, the new rates issued this week do not have the cuts originally intended  (Obama Administration Retreats On Private Medicare Rate Cuts).

Now let's move  away from the ACA and towards reforming the overall health system.  First up, this week we saw some interesting stories about the use of specific care.  Wonk superstar Nate Silver weighed in on the mammogram debate attempting to objectively discuss this very emotional topic on his new fivethirtyeigt.com website:   Are Mammograms Worth It?.  Across the pond there was the release of a new study indicating that Tamiflu - a drug many governments stockpile in case of a flu epidemic - may not be any better than acetaminophen.  This story also highlights the need for true transparency with respect to study data - an issue perhaps as important as the issue of transparency with respect to prices:  What the Tamiflu saga tells us about drug trials and big pharma.

Alzheimer's is the focus of this month's Health Affairs journal:  April 2014; Volume 33, Issue 4: The Long Reach Of Alzheimer’s Disease.  And some good news out of Minnesota with more proof that spending money on items other than direct medical interventions can have a big impact.  Here money was spent on support for caregivers of Alzheimer's patients, thereby keeping people out of institutions because their caregivers were better able to cope with keeping them at home longer (Alzheimer’s Disease Support Model Could Save Minn. Millions).

Moving even further on the aging process, some great pieces on the end of life issue.  It's not secret we don't deal with that well either within society or within our health care system.  My feeling is the more we talk about it, the better we'll be able to cope and make good decisions (Answers to Tough Questions About Dying, A ‘Code Death’ for Dying Patients).
And finally, a few more stories that I found interesting this week:      
Finally, for those who missed it I was a guest blogger over on enroll207.com earlier this week discussing the end of the ACA's first open enrollment period:  The End of the Beginning.

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"
Posted by at
Subscribe to: Posts (Atom)