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New Data on ACA Enrollment Shows Problems in Many States

Jan 14, 2014• 7

By Seth J. Chandler

The Department of Health and Human Services released updated data yesterday on enrollment on the Exchanges including, for the first time, greater breakdowns on enrollment by several key categories: age, gender, and the metal level of purchase.

The result of this long awaited and much requested data is, at first glance, very much a mixed picture. Some of the overall statistics do not look as problematic as some — including me — had feared they might be. But it looks as if there is a very serious potential for large adverse selection problems brewing in a number of states, most notably West Virginia, Mississippi, Maryland and Washington State.

The good news for the ACA from the data

There are three major pieces of good news for those who support the goals of the ACA.

1. The overall gender distribution of enrollees, 54% female, 46% male does not appear on preliminary inspection to be sounding “red alert.” To be sure, the problem may be a little greater than would otherwise be suggested by the aggregated numbers if the middle age group is more heavily female and the oldest group of enrollees more heavily male that the aggregated numbers suggest. And Mississippi is troubling with 61% female enrollment (and for other reasons, see below).

But, overall, and if they hold up, these do not appear to be the the kind of numbers that would be way beyond what insurers likely expected or that, standing by themselves, would be devastating to an insurer on an Exchange.

2. Several states have total enrollments and the age distributions that should reduce the possibility of a serious death spiral getting started. New York and California are the two big states doing better than most. Connecticut is doing very well also.

3. The metal tier distribution is 80% for Bronze and Silver policies and only 20% in Gold and Platinum. That’s comforting for adverse selection. A higher proportion of enrollment in the more generous plans would have been a warning sign that enrollment was coming disproportionately from the sick.

There’s a footnote on this point later on — we are not out of the woods — but this is definitely better news for the ACA than a distribution of, say, only 50% Bronze and Silver purchases.

The bad news

Just because the ACA is doing better than some had forecast on an overall basis does not mean there will not be very serious problems in some states. Given that the statute is presently unamendable as a practical matter, problems in just a few states can hurt a lot of people.

The data released by HHS yesterday shows that there are a number of states in serious trouble.

Let’s Decriminalize Our Health Records

Jan 10, 2014• 12

By Adrian Gropper, MD

The governor of Vermont, Peter Shumlin, devoted all of his annual speech to the problem of drug addiction. On the national news, Shumlin points out the link between prescription painkillers and death, and he calls for treating opiate addiction as a medical problem no different than cancer. The White House praised the governor’s position.

Meanwhile in another part of Washington, I’m involved in the federal effort to link the law enforcement Prescription Drug Monitoring Program databases to the health records physicians use, and to link the databases across state lines.

The unintended consequences of criminalizing addiction and driving medical problems underground need to be considered here as well.

Physician-patient confidentiality is important to public health, and networked electronic health records have both individual privacy and public health consequences. Privacy is essential in infectious disease testing, domestic violence, mental health, adolescent, reproductive, and addiction medicine. Subjecting clinical encounters to law enforcement surveillance beyond the physician’s discretion is life-threatening.

Well-meaning people are now working to link PDMP databases to EHRs and across state lines. The evidence to justify the coerced crossing of the criminal – medical boundary is anecdotal findings in pilot studies that more physicians are in a position to uncover addiction and offer treatment.

The other goal is to reduce illegal diversion of prescription drugs by both physicians and patients. What could possibly go wrong?

One Libertarian’s Dilemma: Genetic Testing or the FDA

Jan 10, 2014• 10

By Saurabh Jha, MD

An advantage astrologers have over genetic testing is that the prediction of astrologers are personally verifiable. An astrologer once emphatically stated that I had no chance of a career in international cricket or Bollywood. So far both claims have turned out to be remarkably accurate.

How does one personally verify a “12.5 %” increased chance of lung cancer, the sort of number the vendor for genetic testing 23andMe produces? If one develops lung cancer how would one know that the chances were indeed 12.5 %, not 6.25 % or 25 %?

We die only once. Whether one ends up with lung cancer or doesn’t, the veracity of the claim can be made only empirically. Meaning we need to see how many develop lung cancer out of 10, 000 people just like us.

Yet there is an element of scientific precision in the number, augmented by the decimal point. And it is precisely because genetic testing tends towards science not metaphysics that it falls within the dominion of the Food and Drug Administration (FDA). FDA does not regulate palm readers.

FDA has asked 23andMe to stop sales of its genomic testing.

As a libertarian seeped in the Austrian school of Economics, I am generally disposed against regulations. I also share the sentiments of the monetarist Milton Friedman that the true costs of the FDA must also include the treatment opportunities foregone in their lengthy review process.

So it hurts me to be somewhat sympathetic of FDA’s stance on 23andMe, even as I think an outright ban was a tad harsh.

The Data Are Wrong. Our Patients Are Sicker!!!

Jan 9, 2014• 14

By Paul Levy

People in health care don’t like it when numbers emerge that are uncomfortable. Take these, issued today by the Massachusetts Health Policy Commission in its latest report on the drivers of the high cost of care in our state.

Variation, particularly when not correlated to quality of outcome, is particularly troublesome for some incumbents. Academic medical centers often have their answer, but as the HPC explains, it doesn’t hold water:

One oft-cited theory for the cause of this variation is that certain types of hospitals, such as those that teach physician residents and fellows, must incur additional expenses to support their mission. However, the difference in median expenses per discharge between teaching hospitals and all hospitals ($1,030) was less than the difference between individual teaching hospitals ($3,107 between the 75th percentile and 25th percentile teaching hospitals). Moreover, there were a number of teaching hospitals that incurred fewer expenses per discharge than the statewide all-hospital median of approximately $9,000 per discharge.

So perhaps the high cost ones will now revert to the usual squawking: “This isn’t fair. The data are wrong. Our patients are sicker.”

Except here, the data are the best that could be available–all the claims for all the hospitals and all the payers in the state–even adjusted for wages. And the acuity of patients across the spectrum of academic medical centers does not vary widely–but, just in case, the numbers are case-mix adjusted.

Gender Could Be as Big a Problem as Age for the Affordable Care Act

Jan 9, 2014• 2

By Seth J. Chandler

Concerns about whether insurance sold on the individual Exchanges under the Affordable Care Act will succumb to an adverse selection death spiral have focused mainly on the shortage of younger enrollees into the system.

This shortage is potentially a problem because, due to section 1201 of the ACA, premiums for younger enrollees must be at least one third of that for older enrollees even though actuarial science tells us that younger enrollee expenses are perhaps just one fifth of those for older enrollees.

Younger enrollees are needed in large numbers to subsidize the premiums of the older enrollees. But at least premiums under the ACA respond at least somewhat to age.

The lesser studied potential source of adverse selection problems, however, is the fact that medical expenses of women for many ages are essentially double those of men and yet the ACA forbids rating based on gender.

In a rational world, one would therefore expect women of most of the ages eligible for coverage in the individual Exchanges to enroll in plans on the Exchange at a higher rate than men. But, since the women have higher than average expenses than men, premiums based on the average expenses of men and women will prove too low, creating pressure on insurers to raise prices.

And, of course, there could also be some disproportionate enrollment by older men who have higher medical expenses than women of equal age. While I welcome contrary arguments in what I regard as a fairly new area of study involving the ACA, gender-based adverse selection would certainly appear to be a real problem created by the structure of that law.

To me, it looks to be potentially as large a problem as age-based adverse selection. It is certainly one that needs continuing and careful evaluation.

Caveats
I see only three limited factors that reduce what would otherwise appear to be a significant additional source for significant adverse selection. As set forth below, however, I do not believe that any of these factors are likely to materially reduce the problem.

1. Ignorance
The first is ignorance. Adverse selection emerges only if individuals can accurately foretell their future medical expenses with some accuracy. To the extent, therefore, that men and women are ignorant of the effect of gender on their projected medical expenses, adverse selection is potentially diminished. I say “potentially,” however, because of a subtlety: people don’t have to know why their expenses are what they are in order for adverse selection to emerge; they only have to be somewhat accurate in their guess.

Thus, even if men and women don’t make the cognitive leap from seeing lower (or higher) medical expenses to issues of gender, but they still on balance get it right, adverse selection can exist. Thus, I end up doubting that ignorance of the correlation between gender and medical expense is going to retard adverse selection problems very much.

Do You Care About My Health, Or Just Think I’m Gross? Be Honest.

Jan 8, 2014• 19

By S.E. Smith

Hi. I’m fat. I’m what most people call an in-betweenie—I have a heavy build, I wear plus sizes, my stomach poofs out, I have folds of fat along my back, I have chubby arms and legs. I can still buy clothes off the rack at a lot of stores, though.

Don’t rush to tell me I’m not ‘that kind’ of fattie or you’re ‘not talking about [me]‘ when you’re going on about how much you worry for fat people, though. We all know that you’re thinking of me, that when you think of fat people, my double chin comes to mind, my wobbling upper arms, my thighs broad in my jeans, my big ass. I’m fat. It’s okay. You can say it. I don’t have a problem with it.

I have a lot of issues with my body, but my size isn’t really one of them. It is what it is. The reasons I’m fat are complicated and not really your business. And yeah, I am unhealthy, and the reasons for that aren’t your business either, although I know you want to rush to assume that I’m unhealthy because I’m fat.

I don’t have an obligation to be healthy, actually, and I don’t have an obligation to rush to assure you that I’m a ‘good fatty’ with great cholesterol and good scores on other health indicators allegedly related to weight. I don’t have an obligation to tell you that fat isn’t correlated with health because I shouldn’t have to justify the existence of fat people by informing you that you don’t understand how fat bodies work, and you’re not familiar with the latest studies on fatness, morbidity and mortality, health indicators, and social trends.

Actually, We’d Probably All Be Better Off With Our Health Records on Facebook

Jan 6, 2014• 19

By Melissa McCormack

A Facebook user’s timeline provides both a snapshot of who that user is and a historical record of the user’s activity on Facebook. My Facebook timeline is about me, and fittingly, I control it. It’s also one, single profile. Anyone I allow to view my timeline views my timeline—they don’t each create their own copies of it.

Intuitive, right? So why don’t medical records work that way? There is no unified, single patient record—every doctor I’ve ever visited has his or her own separate copy of my records. And in an age where we can conduct banking transactions on my smartphone, many patients still can’t access or contribute to the medical records their doctors keep for them.

My proposal? Medical records should follow Facebook’s lead.

Cross-industry innovation isn’t new. BMW borrowed from the tech world to create its iDrive; Fischer Sports reduced the oscillation of its skis by using a technologycreated for stringed instruments. So I asked myself: Who has mastered the user-centric storing and sharing platform? The more I thought about it, the more I decided a Facebook timeline approach could be just what medical records need.

To see what I mean, let’s explore some of Facebook timeline’s key features to see how each could map to features of the ideal medical record.

“About” for Complete, Patient-Informed Medical History

On Facebook: The “about” section is the one that most closely resembles the concept of a user profile. It includes a picture selected by the user and lists information such as gender; relationship status; age, political and religious views; interests and hobbies; favorite quotes, books and movies; and free-form biographical information added by the user.

In medical records: The “about” section would be a snapshot of the patient’s health and background. It should include the patient’s age, gender, smoking status, height, weight, address, phone number, and emergency contact information; the patient’s primary care provider; and insurance information. This section would include a summary list of the patient’s current diagnoses and medications, as well as family history. And importantly, both the doctor and the patient would be able to add details.

“Privacy Settings” and “Permissions” for Controlled Sharing

On Facebook: Privacy settings allow users to control who can see the information they post or that is posted about them. For example, in my general privacy settings I can choose to make my photos visible only to the people I’ve accepted as “friends.” However, if I post a photo I want the entire world to see, I can change the default setting for that photo to be visible publicly instead.

Facebook also allows users to grant “permissions” for outside applications to access their profiles. For example, let’s say I use TripAdvisor to read travel reviews. TripAdvisor lets me sign in to its site using my Facebook account, rather than creating a separate TripAdvisor account. But, to do this I must grant TripAdvisor “permission” to access my Facebook account.

In medical records: Patients could use “privacy settings” to control whether all or part of their information can be seen by a family member or caregiver. For
example, if my aging mother wanted to give me access to her “events” (upcoming doctor’s appointments), she could do so. If my college-aged son who is still on my health plan wanted to give me access to his knee X-rays, he could.

Ten Health and Wellness Resolutions Not to Make in 2014

Jan 5, 2014• 22

By Vik Khanna & Al Lewis

We don’t make a lot of New Year’s predictions, but we are happy to make this one: 2014 will be the year the get-well-quick mentality driving corporate and individual health choices implodes…and people start taking genuine steps to be healthy. The way to ensure that 2014 is your year for good health? Start with a double negative: (a) wellness industry advice is almost always wrong; and (b) most people don’t keep their New Year’s resolutions. Hence, making the New Year’s resolutions recommended by the wellness industry is not the best way of ensuring your good health in 2014.

For simplicity, we’ll divide this list into individual and corporate wellness industry resolutions, and start with individual ones.

Take more health advice from celebrities. Whether it’s hoping that Kim Kardashian’s personal trainer can help you or pining for Dr. Oz to cure what ails you with green coffee bean extract and raspberry ketones, a good way to put off doing worthwhile things is to do worthless ones.
Start a weight loss program. The medical establishment could not head off the obesity dilemma at the pass, and they have no solution for it now, other than to crow about more drug companies diving into this expanding market. There is zero evidence that weight loss programs can produce sustainable long-term weight loss (and much evidence that they don’t), and we don’t know of a single one shown to improve fitness. That will not, however, prevent weight loss companies from trying to claim their little piece of the wellness landscape because they are losing so many individual customers to free dieting apps, such as LoseIt.com. Improve the quality of your diet first, and weight loss may follow, which is a bonus.
Give yourself a cleanse. America’s obsession with cleanliness is now running smack into the reality of evolution and human physiology. Surely if bacteria in your colon were bad for you, mankind would have died out eons ago.
Stock up on supplements. The only things better than raspberry ketones and green coffee bean extract: all the other vitamin and mineral supplements on the market that fail to make sick people better or healthy people healthier. Who’s left to try to help, Martians? Never mind that risk is not endlessly reducible and the four most important things you can do for your health don’t come out of a bottle of magic jujubes: exercise, don’t smoke, eat well, and keep as close to a healthy weight as you can.
Remove saturated fat from your diet. Just like in the 1960s, when we all traded in “the high-priced spread” for sticks of partially hydrogenated vegetable oils fit for a king to avoid saturated fat, we may be mis-demonizing this longstanding and naturally occurring component of our diet. The entire nutrition dialectic in our culture over the past 20 years has focused on a string of individual no-nos: fat, saturated fat, cholesterol, and now refined grains and sugars (because we bought the government’s wrong advice to eat low-fat). It’s time to revive the notion of healthy eating patterns, not healthy eating isolates. In fact, here is the world’s simplest diet advice for 2014: eat less junk. That alone would be a landmark nutritional achievement for Americans.
Eat organic and stay away from Starbucks. Within a week of each other, the New York Times published an account of a woman damaging her health eating an obsessively healthy and organic diet, and USA Today wrote of another who ate exclusively at Starbucks for a year, with no apparent ill effects and no weight gain.

Twelve Things We’re Pretty Sure We’ll See Happen In Health Care In 2014

Jan 3, 2014• 11

By Jaan Sidorov, MD

While your humble columnist eschewed forecasting for 2013, he has decided to reverse course and inaugurate the 2014 blogging season with a contrarian duodecimal exercise in futurism. Will this antidecimal augury align with the mysterious cosmic order and governing perfection? Let the readers be the judge in January 2015……

1. Obamacare will neither succeed or fail. This hugely complex law will have too many outcomes, statistics and analyses that will be subject to too much spin by both supporters and detractors. Like puppies clamoring for the mother’s attention, the loudest wins, but only in 15 minute media increments.

2. Inflation returns, with a vengeance: While we won’t know it until well into 2015 or 2016, 2014 will be the year that the sleeping giant of healthcare costs awakens. Millions of new insureds in an improving economy will finally get their pent-up pricey preference-sensitive health care needs fulfilled.

3. Duh, it’s the delays stupid: While low income Americans will appreciate having access to subsidized health insurance and Medicaid, the middle class’ unsubsidized sticker shock will threaten the fall 2014 elections. Caught between conflicting advice of insurance actuaries and political hacks, the White House’s regulatory choices will be obvious.

4. Commercial scientific misconduct: Unable to resist the allure of bonus payments (like this) or the branding that is dependent on the public release of quality outcomes, at least one large health entity will be caught committing “reporting fraud.”

5. Snowden blow-back: as the promise of big-data grows, fearful health care consumers will be even less inclined toward allowing access to their health information. Too bad they won’t be given a say.

6. Innovator’s Dilemma for health tech: solutions that are simple, transparent and modular will continue to make ‘from the bottom’ inroads into a tech industry that – like early data storage – is too complex, opaque and entangled.

7. Speaking of health tech, patient-monitoring solutions that offer more insight and less data will grab market share. Instead of a series of blood glucose results dumped into an electronic inbox, think algorithms that suggest insulin dose adjustments.

Headlines You’ll See in 2014

Jan 2, 2014• 59

By Paul Keckley

Affordable Care Act major issue in Campaign 2014; ‘fix and repair’ new focus. ObamaCare will be the defining issue in the coming election cycle, but the political debate will not be Healthcare.gov glitches or enrollment.

Rather, the issue will be sticker shock in insurance premiums and the complaints from doctors and hospitals that they’re being driven out of business. “Repeal and Replace” will not be heard; the new slogan will be ‘fix and repair’ for both friends and foes of the ACA.

Hospitals battle for survival. Faced with negative operating margins, sequester cuts and mounting bad debt, state and local officials and hospital boards will take dramatic steps to insure acute services survive. Some will merge local hospitals to be operated as a public utility.

Some academic medical centers will spin off their research enterprises into commercial ventures with bio-pharma and device partnerships. Some will merge or sell out to larger systems with stronger balance sheets.

And all will reduce operating costs and purge clinical programs no longer affordable. As patient demand and their severity increase, hospitals will operate their inpatient business as a cost center, and their enterprises as regional care management organizations assuming risk for costs, outcomes and safety. But none is delusional: hospitals face a battle for survival.

Physicians go it alone; holy war for future of the profession taking shape. Led by the American Medical Group Association and several specialty societies, large medical groups will join forces to advance a physician-centric platform for health reforms that protect physician-patient relationships, position primary care physicians as gatekeepers, and assume financial and clinical risk in contracts with insurers and employers via fully integrated health plans operated by the group.

Physicians will step up their political activism in 2014, armed with data showing their net incomes have suffered and their clinical autonomy compromised since the onset of health reform. In 2014, they’ll wage unsuccessful battles for replacement of the SGR and liability reform again.

And they’ll dust off advocacy advertising campaigns to drum up resentment of market pressures that threaten to deduce their profession to a guild employed by plans or hospitals. For doctors, 2014 will look like a last stand for the profession.

Occupy Health Care Breaks out; profits with purpose sought. Income inequality in the U.S. will spill over into health care in 2014. The social media fueled visibility of earnings and executive compensation in every sector of health care will spark local political activism.And interest in a single payer system will begin to build heading into the 2016 election cycle.

Just as value will be challenged, so will the morality of the U.S. health system, and a populist campaign to align profit with purpose sought.