… and a call to action. This case study is based on my meeting with the Center for Health Information and Analysis (CHIA) in my home state. CHIA is an all payers claims database, a massive collection of diagnoses, locations, dates and prices for all of your health services across all of your providers and insurers. Whether it’s claims or health records, almost every state and many private clearing houses are setting up to monitor you.
Your information can be used by business to manipulate prices for maximum profit, or by you to inform your choice of health insurance plans and health care providers.
Unfortunately, business can get your information but you can’t. This reflects an industry strategy to obstruct the market-based features of the Affordable Care Act. I hope you will take this case study, edit it, and file it with the Attorney General and Governor in your state to ask for your data as a consumer protection issue. That’s what I’m about to do.
My state is #1! Go Massachusetts! My state is #1 in health care costs. It’s also #1 in implementing a health insurance exchange (Romneycare 2006) and a leader in state surveillance with the 2012 cost containment law known as Chapter 224. Chapter 224 mandates various state surveillance mechanisms including a health information exchange that monitors encounters and an all payer claims database called “the center”.
The cost containment law also includes some consumer protections. Line 1909 states:
“To the maximum extent feasible, the center shall also make data available to health care consumers, on a timely basis and in an easily readable and understandable format, data on health care services they have personally received.”
Although the state surveillance is in place, and the price fixing that keeps us #1 is ongoing, the consumer protection part of the law is not implemented. So, I took the opportunity to meet with the executive director of CHIA and their chief legal counsel and get the scoop on why the state is not following the law. To paraphrase their explanation: “It’s too hard.”
Continue reading “State Surveillance Endangers the Affordable Care Act: A Case Study”
Filed Under: THCB
Tagged: Adrian Gropper, Center for Health Information & Analysis (CHIA), Consumer Directed Healthcare, Health Insurance Exchanges, Health Plans, Massachusetts, Pharma, The Affordable Care Act, The States
Oct 18, 2013
How did it go? Unavoidably, that will be the big question come Tuesday.
But there will be much more to it than that.
A 180-Day Open Enrollment––Not a One-Day Open Enrollment
What happens on the first day, for good or bad, will constitute only a tiny percentage of the open enrollment period. Consumers will likely visit the new websites many times before they make any decisions, and that is exactly as it should be.
Many of the health plans touted as being low-cost plans are going to be very limited access plans. It won’t be easy for consumers to compare one plan’s provider network to the other. In the best of circumstances, consumers will be confused by what is being offered for some time and will have to make a major effort to make sense of it for themselves.
Let’s not forget, they will be buying something that will cost thousands of dollars––their money or the government’s––and that kind of purchase will never be as simple as going to Amazon and buying a book.
I will suggest that if the local press wants to be helpful they will waste less time asking how things went the first day and more time doing stories on the quality of the various health plans in their local communities––particularly over provider access, which will be the only major product differentiator between health insurance companies.
Will There Be Administrative Problems With the Exchanges?
There already are. And, there will be lots more.
During the last 24-hours I have been told that the information technology testing between insurance companies and the federal government, particularly around the government telling insurance companies who they will be covering, continues to be a real mess.
But whatever obvious problems there are at launch, there will likely be more problems and more serious problems behind the scenes in the lead-up to January 1, the initial problems will be worked out in a few days or a few weeks. Operational expectations are now so low for Obamacare’s health insurance exchanges a small disaster will be considered a political victory.
Continue reading “Will Obamacare Survive? Nine Key Questions”
Filed Under: OP-ED, THCB
Tagged: Benefit shock, Exchanges, Massachusetts, Obamacare, Open Enrollment, Rate Shock, Red states, Robert Laszewski, The States, White House
Sep 29, 2013
Putting aside a lengthy discussion over the merits of and cost saving potential of EMRs for a minute, comes this gem from the land of not so well thought out policy making…
In 2010, the Massachusetts Legislature passed a law requiring that, as a condition of licensure starting in 2015, Massachusetts physicians must demonstrate proficiency in the use of electronic health records, computerized order entry, e-prescribing, and other forms of health information technology.
Last year [ in chapter 224], the Legislature amended that statute to state that physicians must “demonstrate the skills to comply with the ‘meaningful use’ requirements.” There was no further language to explain the intent or scope of that amendment.
Given that even the most optimistic forecast holds that only 12,000 eligible providers in Massachusetts would achieve Meaningful Use certification by 2015 (more than 30,000 physicians hold a Massachusetts license), the MMS is committed to ensuring that the statute is interpreted broadly, and does not unintentionally disenfranchise thousands of physicians, thereby creating an extreme health care access issue.
-Massachusetts Medical Society
So 60% of doctors are projected to be non-compliant?!? I guess a doctor shortage will take on a whole new meaning in the state.
This is what happens when you pass major policy bills in 14 hours without anyone reading the whole thing first, but I digress…
This issue prompted a recent call to action from a local doctor in North Chelmsford, Dr. Hayward Zwerling.
Josh Archambault is director of health care policy at the Pioneer Institute in Boston (www.pioneerinstitute.org), publisher of “The Great Experiment: The States, The Feds and Your Health Care.”
Filed Under: Physicians, THCB
Tagged: EHR, Josh Archambault, Massachusetts, Physicians
Jun 8, 2013
Last summer, the Commonwealth of Massachusetts enacted legislation that will fundamentally alter the physician-patient relationship by giving politicians the right to specify the processes that must occur during an office visit. The relevant law is Section 108 of Chapter 224 of the Acts of 2012, which reads as follows:
The first paragraph of section 2 of chapter 112 of the General Laws … is hereby amended by inserting (the following)… The board (of Registration in Medicine) shall require, as a standard of eligibility for (medical) licensure, that applicants demonstrate proficiency in the use of computerized physician order entry, e- prescribing, electronic health records and other forms of health information technology, as determined by the board. As used in this section, proficiency, at a minimum shall mean that applicants demonstrate the skills to comply with the “meaningful use” requirements (1).
Thus, any Massachusetts physician who does not use a Federally certified EMR AND meet the contemporary Meaningful Use requirements will be denied a license to practice medicine effective 2015. Most unfortunately, the Meaningful Use mandates will continue to become every more onerous in Stages 2, 3, 4, 5, 6 and 7.
As we all know, the practice of medicine has become increasingly difficult as a result of external mandates. These mandates specify which medicines we may prescribe, which radiology tests we can order, how many days our patients are allowed to remain in the hospital, which CME classes we must take, etc. And now, the politicians intend to tell physicians which software they must use in their office and which EMR options must be utilized during the office visit.
The Government’s decision to foist “certified” EMRs on the medical profession is predicated on the hypothesis that the widespread adoption of EMRs will eventually reduce the cost of healthcare. Unfortunately, data published to-date does not support this hypothesis (2). Thus, the continued imposition of the EMR mandates will only delay the implementation of a truly effective solution that could reduce the cost of healthcare.
As the developer of an EMR, I sincerely believe that a well designed EMR is a useful tool for many practices. However, the Federal and State Government’s misguided obsession to stipulate which features must be in the EMRs, and how the physician should use the EMRs in the exam room places the politicians in the middle of the exam room between the patient and the physician, and seriously disrupts the physician-patient relationship.It is past time that physicians reclaim control of their offices, if not the practice of medicine.
Continue reading “The EMR Use Rule: An Open Letter to Massachusetts Physicians”
Filed Under: OP-ED, Physicians, THCB
Tagged: doctor/ patient relationship, EHR, Hayward Zwerling, Massachusetts, Physicians
May 27, 2013
American consumers know more about the quality and prices of restaurants, cars, and household appliances than they do about their health care options, which can be a matter of life and death. While we have made some progress in getting consumers reliable quality information thanks to organizations like Bridges to Excellence and The Leapfrog Group, for most Americans, shockingly little information still exists about health care prices, even for the most basic services. And several studies have shown us that the price for an identical procedure can vary as much as 700 percent with no difference in quality. Moreover, with health care comprising 18 percent of the US economy and costs rising every day, it is extremely troubling that most health care prices are still shrouded in mystery.
Our organizations have been steadily pushing health plans and providers to share price information more freely, and we are seeing progress. But public policy—or even just pending legislation—can provide a powerful motivator as well.
Unfortunately, our new Report Card on State Price Transparency Laws shows most states are not doing their part to help consumers be informed and empowered to shop for higher value care. In the Report Card released Monday, 72 percent of states failed, receiving a “D” or an “F.” Just two, Massachusetts and New Hampshire, received an “A.” The Report Card based grades on criteria including: sharing information about the price of both inpatient and outpatient services; sharing price information for both doctors and hospitals; sharing data on a public website and in public reports; and allowing patients to request pricing information prior to a hospital admission.
Continue reading “States Must Step Up to Help Consumers Gain Access to Health Care Prices”
Filed Under: OP-ED, THCB, The Business of Health Care
Tagged: Catalyst for Payment Reform, consumer-patients, Costs, Francois de Brantes, Health Care Incentives Improvement Institute, Hospitals, Massachusetts, New Hampshire, Quality, Suzanne Delbanco, The States, Transparency
Mar 18, 2013
In 2006, Governor Mitt Romney signed Chapter 58 of the Acts of 2006 entitled “An Act Providing Access to Affordable, Quality, Accountable Health Care.” It has been described by many names, including Massachusetts Healthcare Reform (MHR), Romneycare, or simply, as the template for the Affordable Care Act. The goal of the act was straightforward: to ensure near-universal access to health insurance for citizens of the Commonwealth of Massachusetts. The bill quickly led to insurance expansion: by 2010, 94.2% of adults under 65 had health insurance, an 8 percent increase over the 86.6% in 2006. By all accounts, the goals of insurance expansion were met.
But the bill has not been without controversy. There have been two main concerns: first, that the bill did too little to control rising healthcare costs. The cost crisis led to the 2012 bill that many refer to as “Mass Health Reform 2.0” – formally called Chapter 224 of the Acts of 2012. Its focus is to curtail healthcare spending, and while reasonable people have reasons for skepticism about the likelihood of success, that’s a topic for another day.
Continue reading “Did Massachusetts Health Care Reform Hurt Access To Care For the Previously Insured?”
Filed Under: OP-ED
Tagged: Ashish Jha, Florida, Health Care Reform, Health Insurance Exchanges, hospitalization, Massachusetts, Medicare, Romneycare, Texas, The Affordable Care Act
Mar 5, 2013
A recent article in Time magazine by Steven Brill, “Bitter Pill: Why Medical Bills Are Killing Us,” is a brilliantly written expose of the excesses and outrages of health care pricing. In reaction to the story, some have suggested the price controls are the appropriate (or the only) way to rectify the situation. A recent story in the Washington Post’s Wonkblog, “Steven Brill’s 26,000-word health-care story, in one sentence,” suggests that US health care costs and cost growth are so high because we do not use rate setting, i.e., price controls.
In fact, I think it’s not easy to establish whether that is indeed the case. We don’t get to use randomized controlled trials for health policies or systems, so it’s difficult to figure out how effective a policy like rate setting is. Let me start with some simple examinations of patterns in data to see if something jumps out that strongly supports (or contradicts) the assertion that price controls reduce health care costs.
Continue reading “Are Price Controls the Answer?”
Filed Under: OP-ED, THCB
Tagged: Costs, Economics, health economics, Managed Care, Martin S. Gaynor, Massachusetts, Medicare, Price controls, rate settings, Steven Brill
Feb 27, 2013
A bureaucracy-centric governing philosophy is spreading in health care, and with it comes heavy reliance on “experts” to determine how to curb costs outside the normal legislative and democratic process. This was embodied at the national level by the Affordable Care Act (ACA), and most recently at the state level in a new Massachusetts growth-capping law. (Supporters refer to the law as cost control and payment reform or Health Reform 2.0; the legal name is Chapter 224 of the Acts of 2012).
The new Massachusetts law was discussed by Mechanic, Altman and McDonough in a past Health Affairs issue, and on the blog by Turnbull and Lee. Yet, the unintended consequences of using this method to reform health care have not been fully explored.
What’s In The Law?
Promising savings of $197 billion over 15 years, Chapter 224 sets a cap on statewide health care spending growth by tying it to state growth, enforced by a flat $500,000 civil penalty if health care entities don’t meet reporting deadlines or take reform efforts seriously enough. The law grants strict preference to alternative payment methods (capitated or bundled payment contracts) and accountable care organizations (ACOs).
Continue reading “Now For The Rest Of The Story On Massachusetts Cost Control”
Filed Under: THCB, The Business of Health Care
Tagged: Josh Archambault, Massachusetts
Feb 27, 2013
For the third year in a row, national health spending in 2011 grew less than 4 percent, according to the CMS Office of the Actuary. However, the report said modest rebounds in pharmaceutical spending and physician visits pointed toward an acceleration of costs in 2012 and beyond. CMS’s analysts make much of the cyclical character of health spending’s relationship to economic growth and also forecast a doubling of cost growth in 2014 to coincide with the implementation of health reform.
This non-economist respectfully disagrees and believes the pause could be more durable, even after 2014. Something deeper and more troublesome than the recession is at work here. As observed last year, the health spending curve actually bent downward a decade ago, four years before the economic crisis. Health cost growth has now spent three years at a pre-Medicare (indeed, a pre-Kennedy Administration) low.
More Than The Recession Is At Work
Hospital inpatient admissions have been flat for nine years, and down for the past two, despite compelling incentives for hospitals to admit more patients. Even hospital outpatient volumes flat-lined in 2010 and 2011, after, seemingly, decades of near double-digit growth. Physician office visits peaked eight years ago, in 2005, and fell 10 percent from 2009 to 2011 before a modest rebound late in 2011 — all this despite the irresistible power of fee-for-service incentives to induce demand.
The modest rebound in pharmaceutical spending (2.9 percent growth) in 2011 appears to have been a blip. IMS Health reports that US pharmaceutical sales actually shrank in 2012, for the first time in recorded history, and that generic drugs vaulted to the high 70s as a percent of prescriptions!
There is no question that the recession’s 7-million increase in the uninsured depressed cost growth. But the main reason health cost growth has been slowing for ten years is the steadily growing number of Americans — insured or otherwise — that cannot afford to use the health system. The cost of health care may have played an unscripted role in the 2008 economic collapse. A 2011 analysis published in Health Affairs found that after accounting for increased health premium contributions, out-of-pocket spending growth and general inflation, families had a princely $95 more a month to spend on non-health items in 2009 than a decade earlier. To maintain their living standards, families doubled their household debt in just five years (2003-2008), a debt load that proved unsustainable. When consumers began defaulting on their mortgages, credit cards and car loans, the resultant chain reaction brought down our financial markets, and nearly resulted in a depression.
By sucking up consumers’ income since 2008, the rising cost of health benefits has weighed heavily upon the recovery. According to the 2012 Milliman Cost Index, the cost of health coverage rose by 32.8 percent from 2008 to 2012, while family income did not grow at all in real terms. The total cost (employer and employee contributions plus OOP spending) of a standard PPO policy for a US family of four was $20,700, almost 42 percent of the US household median income in 2012.
Continue reading “The Gold Plated Health Care System: What the New Numbers Tell Us about the State of the Economy”
Filed Under: Economics, THCB, The Business of Health Care
Tagged: California, CMS, CMS Office of the Actuary, Costs, Health care spending, Health Insurance Exchanges, Jeff Goldsmith, Massachusetts, Medicaid Expansion, The Affordable Care Act, The States
Feb 2, 2013
Thanks to David Kerrigan of the Massachusetts Health Connector for pointing out that the Obama Administration has suddenly switched terminology: health insurance exchanges are now health insurance marketplaces. I think it’s a great idea, which is why I wrote a blog post on this very topic on Friday. The Hill (Obama officials ditch ‘exchanges’ in rebranding of healthcare reform law) covers the story.
However, the Hill has a weird angle on this. The article heavily features an anti-ObamaCare activist, Dean Clancy who says:
“They could call them motherhood or apple pie, but it wouldn’t change our feelings about them… We’re encouraged that they’re showing signs of desperation. I think that it’s too late in the game to try to start calling this something different. And [we’re] not going to spend a lot of effort fighting over a word.”
Clancy’s website is called blockexchanges.com, so he may actually have more commitment to the word exchange than the Obama folks. Somehow blockmarketplaces.com just doesn’t have the same ring to it. (That domain is still available at this writing in case you want to grab it.) Blockexchanges also has some misleading information on its home page:
“Remember, without the state exchanges, ObamaCare cannot function.”
Actually, the federal government will step in if the states don’t.
Personally, I don’t sense desperation but rather a gradual wising up about what implementation will require. The term “marketplace” makes a good deal of sense for someone who is comparison shopping for health insurance. Here’s to more commonsense improvements as ObamaCare is rolled out.
David E. Williams is co-founder of MedPharma Partners LLC, strategy consultant in technology enabled health care services, pharma, biotech, and medical devices. Formerly with BCG and LEK. He writes regularly at Health Business Blog, where this post first appeared.
Filed Under: THCB
Tagged: Connector, David Kerrigan, David Williams, Dean Clancy, Health Insurance Exchanges, Health Insurance Markets, Massachusetts, Obamacare, The Affordable Care Act, The States
Jan 23, 2013