William P. White was among the first insurance commissioners in the nation to push back on the President’s plan to allow some people to keep their current plans. DC Wonks #predictablyoutraged.
More at The Washingon Post.
maithri
What I Expect From the Medicare Program
After half a lifetime of following the Medicare program, on October 1, 2013, I became a Medicare beneficiary. I turned 65 on October 31. I’m part of the leading edge of baby boomers joining the program, ten thousand a day. We’re going to change this program, both by how we use it and what we expect its keepers in Washington to do to improve it.
Here are some reflections upon joining Medicare.
1-Don’t Refer to Me as “Retired”, Please. I’m still working (hard) and paying Medicare as well as income taxes taxes every month. Like most of my fellow boomers, I lack the financial cushion I want in order to stop working. Additionally, for what it’s worth, like all too many boomers, I don’t know how not to work. So my main goal, which is closely aligned with the country’s, is to stay healthy enough to keep working long enough to be able to retire comfortably when I wish to do so.
I plan on staying a long way away from the expensive parts of our healthcare system, if only to avoid being inadvertently harmed. Rest assured that if I know I’m dying, you won’t find me in a hospital if I have any say in the matter.
I don’t consider myself “entitled” to Medicare, or to subsidies from younger people. I’m paying more than $400 a month in Part B fees and the special assessment on Part D that got tacked on in the Affordable Care Act. After what I’ve already paid in, that’s not exactly a flaming bargain. I’ve paid Medicare enough over my working lifetime to buy a house, and will pay more Medicare taxes for years to come for each month that I work. Nothing makes me angrier than the suggestion that I’m somehow sponging off my kids by participating in Medicare.
2- The Regular Medicare Program is a Relic. There is a lot of political fog enshrouding Medicare. Personally, I could care less about the politics of this program. The big choice was fairly cut and dried: either regular Medicare plus a supplemental plan or Medicare Advantage. After logging onto Medicare.gov, I found the regular Medicare benefit completely incomprehensible- chopped up into Parts that may have made legislative sense in the 1960’s. If you included the supplemental coverage, there were just too many moving parts that didn’t seem to fit together into a unified benefit.
So I chose Medicare Advantage. It’s simple to understand and user-friendly, and looks a lot like my previous coverage. My doctor is a participating physician as is my beloved community hospital, Martha Jefferson. And the price is right: zero dollars after my Part B premium. More than 40% of boomers are picking Medicare Advantage, largely because it’s easy to use and remains a bargain. It will eventually be half the program.
Five Questions Journalists Should Be Asking About the Affordable Care Act
I’m hearing a lot of the lazy “but what are the political implication” perpetual horse race questions from the media about recent developments surrounding the Affordable Care Act. That’s fun Inside-the-Beltway stuff, but in the mean time there are real people who are likely to be helped and hurt with matters as essential as their health. So, what I am not hearing enough of yet, however, are tough, substantive questions that get to the heart of whether the Affordable Care Act is going to be stillborn.
Here are some questions that I think intelligent journalists and blogger ought to be asking in light of recent developments with the Affordable Care Act. Getting answers in many cases may take persistent questioning and closer scrutiny of existing documents. In others, FOIA requests may be needed.
1. Actual v. Anticipated Age Distributions in the Exchanges
What is the age distribution by state and in the aggregate of persons who it is claimed have enrolled in Exchange-based plans under the Affordable Care Act? Once we have this data, we can compare it to (a) census data on the age distributions in the various states and (b) any prior estimates on what the age distribution of Exchange enrollees would be such as those described in this government document.
If there is a significant difference between the age distribution encountered thus far and the anticipated age distribution, that increases the probability of the ACA succumbing to an adverse selection death spiral.
What the “Doc Fix” Should Tell You About the “Grandfather Fix”
With his announcement on Nov. 14 of a plan to offer a temporary reprieve to people facing cancellation of their health-care policies, President Barack Obama may have created his own version of the much-maligned, often yearly, Medicare “doc fix”.
The doc fix, a recurring effort by Congress to override statutory formulas that limit the growth in Medicare payments to doctors, often sparks political theatrics as lawmakers work to assuage the concerns of physician groups and Medicare recipients. Many members of Congress want to repeal and replace the underlying program — the sustainable growth rate formula for reimbursing physicians — but agreement has proved elusive, in part because of deficit concerns and the high cost of repealing the formula.
The president may have set himself up for another situation similar to the doc fix with his proposal to administratively tweak the health law. Obama said he will temporarily allow health insurance companies and state insurance commissioners to continue offering insurance plans “that would otherwise be terminated or canceled” for failing to meet the requirements of the Affordable Care Act (ACA).
Has President Obama created his own version of the annual “doc fix” by continuing insurance plans that would have otherwise been canceled?
While this change will help some health-insurance consumers, it is a serious complication for health insurers who in a few weeks will have to readjust their plans. In the 24 hours since the announcement, the initial reaction from insurers and state health insurance commissioners has been mixed. Some insurers have already voiced concerns that any short-term fix will deprive their ACA-compliant exchange plans of the healthier customers needed to keep rates down for everyone, including older, sicker customers.
Fast-forward 11 months to late October, 2014, with the midterm elections imminent and the president’s “transitional policy” about to expire. Will Democrats want the issue of whether people can “keep their health plan if they like it” raising its ugly head again, just as voters are about to cast their ballots?
Could Med Students Help Win the Enrollment War?
State health exchanges are facing many challenges in the recent scramble to enroll their residents in the healthcare marketplace. Among the numerous obstacles, including online systemic glitches (Washington state botched the tax-credit calculation while Maryland’s appears to be having just general technical incompetence) and complete lack of knowledge (according to a recent Gallup poll, 71% of uninsured Americans have no clue what the exchanges are), a critical challenge is the quick generation of a new healthcare workforce, namely enrollment counselors and navigators.
According to the Center for Medicare and Medicaid Services, enrollment navigators are supposed to help people enroll, whether through online or paper applications, determine individual eligibility for various subsidies and assistance programs, and generally educate the public regarding the new health exchanges. Certified application counselors differ slightly from navigators, taking a less involved role in the process, but still serving as assistants to people who need help completing their application.
However, in many states, including Florida (1 navigator per 100,000 uninsured citizens as of October 1st), Georgia (only 4 people were certified to be counselors when the exchanges went live) and California (official numbers will be released on November 14th, but current estimates suggest less than 20% of future counselors are fully certified yet), there is a huge workforce shortage which is both reducing the rate of enrollment and contributing to people’s doubts about the Affordable Care Act in general.
Part of the problem is that many states, for several months now, have purposely made it more difficult for people to become certified enrollment employees; Ohio and Missouri are widely cited as two of those. They have also instituted regulations on what information counselors can and cannot give patients and have tried to implement large fines, such as in Tennessee, which luckily ruled to temporarily restrain these penalties, for those who may unknowingly breach part of the contract.
As a medical student hoping to be more involved in influencing patient care, but unable to do so at a clinical level just yet, the opportunity to serve as an enrollment counselor or navigator is more than timely.
In my home state of California, training and certification to become a Certified Enrollment Counselor is not easy, but it’s doable. The process involves 20 hours of in-person courses, a number of online modules, and a background check. However, the cost of training is compensated—$58 per completed application, to be exact.
Wait. So How Do I Find out if a Specialist Is Covered by My Plan?
A THCB reader in Connecticut writes:
“I’m a pretty level headed person. I’ve been following the Healthcare.gov story in the news and figured it was more of the usual partisan stupidity out of Washington. I decided to do my homework before getting too worked up.
I went on to my state exchange and compared the available plans. Gold. Silver. Bronze. All very logical. I spent some time comparing options and found a plan I liked. So far so straightforward. No complaints. No plan shortage in my state.
The problems started when I picked up the phone and attempted to communicate with a living breathing human being. I figured it would be a good idea to confirm that my OBGYN’s practice is covered. To make a long story short, I have a pretty serious pre-existing condition that could hypothetically kill me. My OBGYN is one of the best in the state. Moving to another practice is NOT AN OPTION.
Knowing how the system works, I called my OBGYN’s office and asked them to confirm that my doctor’s plan was covered. Should be a five minute call. No luck. Sorry. They don’t have the information yet. Probably yes. They helpfully suggest I give the health plan a call. Well, that’s logical, I think to myself. It takes time for new plans to about the plans to make it through the system. So I take their advice.
I call the health plan involved and politely tell them why I’m calling and what I need to know. Guess what? They don’t know either.
When Is Closing an Ongoing Clinical Trial a Betrayal of Participants?
We have become aware of several instances of precipitous and, in our view, egregious and unjustified closures of on-going clinical trials in which a substantial number of patients were already participating in investigational efforts, some involving biopsies for research purposes.
These closures raise serious ethical issues for the research community. We will discuss those issues and some possible changes in how trials are conducted to address the problem. It is our premise that closing on-going clinical trials without scientific, efficacy, or safety justification is an abhorrent affront to all participants in clinical research as well as a fundamental betrayal of the trust that motivates patient participants to enroll in clinical trials.
Cancer patients who accept the risk of an investigational drug are true partners in bringing new agents to market. They hope they will benefit but, regardless of personal benefit/response, they hope the researchers will learn something to help other patients. Patients participate in clinical research for multiple reasons but, particularly in the case of agreeing to undergo mandatory research biopsies, do so because the research has the potential to improve the care, treatment approach, and standards for cancer patients.
They engage in a relationship with researchers based on their trust in the integrity of the researchers and the system within which the researchers work. Any cavalier approach to the commitment patients make to research is indefensible and particularly reprehensible when participants undergo internal organ biopsies.
Violating the trust of these patients also violates the trust the patients place in the investigators, undermining patient confidence in and availability for research. That trust and any violation of it are deepened when the researcher is also a given patient’s treating oncologist.
It is with good reason that human beings who enroll in clinical trials are called participants, not subjects. A participant is one who takes part in something—an active, volitional partner or colleague. A subject is one, mouse or human, who is under the power or authority and at the incontestable will of another or others. That difference between a participant and a subject is significant and germane to this discussion of when and why it is or is not appropriate to close a clinical trial.
Mental Health Parity and the Affordable Care Act
The Obama administration announced on Friday that it will require parity for mental health insurance coverage. That means that health insurers must apply the same copayments, deductibles, and visit limits to mental healthcare as they do for physical health care treatment. Call it fair, call it political, but please don’t call it a good economic or health policy.
The story about how this is fair, or at least politically popular goes something like this: Health insurers are evil and powerful firms that can and will do whatever they want. On the other hand, patients with mental health problems are politically weak and must be protected from the powerful insurers that have no interest in taking care of them.
In this story, the Obama administration rides in on its white stallion and rights the wrongs being perpetrated by the villainous insurance companies. All we need is a damsel in distress, an evil step-mother, and a catchy tune and Disney will sign the movie rights.
The problem with this simplistic story line is that you can replace “mental health” with nearly any other condition and the story would sound just as plausible.
Hospital Exec Pay: If P4P is Good Enough for Doctors, Why Not the CEO?
In my previous blog, I made the argument that whatever strategy we use to improve care in hospitals will not be implemented and executed well without proper focus by hospital leadership. So, it is in this context, that we recently published some pretty disappointing findings that are worth reflecting on.
We examined the pay of CEOs across U.S. hospitals and found that some CEOs got paid a lot more than others. This was not surprising. CEOs of larger, urban, teaching hospitals get paid a lot more than CEOs of small, rural, non-teaching institutions. But the disappointment was around quality: we found no relationship between a hospital’s quality performance and the pay of the CEO. Holding size, teaching, and other factors constant, what was the pay of CEOs of hospitals with high mortality rates?
About the same as CEOs of hospitals with low mortality rates. What about other quality measures? Most of them didn’t really seem to matter, with the exception of patient experience, which correlated nicely with CEO compensation. It seems that when setting CEO compensation, patient outcomes are not a big part of the discussion. How could this be, and why does it matter?
How you set incentives for senior managers says a lot about your priorities. Boards generally set the salary for their CEOs and they clearly reward patient satisfaction scores. That’s good. They also seem to reward the things that build hospital reputations: having the latest technology such as a PET scanner or academic status. But are boards rewarding CEOs based on mortality rates or adherence to basic quality metrics? Not so much. Why not? I’ve spoken to a lot of board chairpersons over the years and the answer is not that they don’t care. Most boards want to reward quality and believe that they do.
The problem is that most board members lack sufficient expertise on quality metrics and can’t decipher, from the large number of quality metrics, which ones are important (like mortality rates) and which ones are not. Hamstrung, they focus on satisfaction but also end up rewarding things that feel like proxies for quality, such as having the latest technology. And here’s the part that’s frustrating – our national efforts on quality measurement and improvement are not helping. We seem to have done very little to prioritize what’s really important, and shine a light on them.
So what do we do to move forward? Some states have started requiring that boards undergo training in quality. Medicare, as a condition of participation, could certainly require that boards (or at least some members thereof) show a degree of expertise with quality. I like these ideas but worry that training programs would themselves be of variable quality, and for some boards it would become an onerous requirement without achieving real gains in expertise.
Of course, if we really want to help boards be more effective and engage healthcare leaders, the biggest thing that we could do is actually reward hospitals, in a meaningful way, based on quality. Yes, we have the value-based purchasing program, and it is well-intentioned. But, as I’ve written before, it has several big problems. First and foremost: the incentives are very weak and there is little reason to believe it will have a meaningful impact on patient outcomes. Second, the measures are diffuse – we have too many of them, some of which matter (mortality) and many which don’t in the absence of the appropriate clinical context (checking the ejection fraction on a heart failure patient). It’s hard for hospital boards to really get a clear signal on what matters if they aren’t seeing it clearly and consistently from national leaders on quality.
Posts of Note: The 2013 Harvard Business School Cyberposium
This past weekend, I attended Cyberposium at Harvard Business School where I was invited to speak on the Healthcare Technology panel. Cyberposium is one of the largest MBA student-run tech conferences in the country and typically gets around 1,000 attendees — students, industry professionals, press, and VCs. This year was no different.
The atmosphere was buzzing. There’s always a certain energy at these events, and when you’re surrounded by individuals who are passionate about innovation and the curiosity and sense of possibility that come with it, it’s an exciting place to be.
The morning’s keynote featured Bill Clerico, CEO of WePay (a competitor to PayPal in the online payments space). Bill told us about his motivations for starting WePay, their journey to raise $20M, and how he and his team worked relentlessly to scale the organization.
His two big takeaways on what it takes to be a successful entrepreneur, especially if you’re just starting out: 1) you have to be scrappy and 2) you have to have maniacal focus on the customer (both when you acquire and service them). I couldn’t agree more. Personally, it was a reminder that as we grow bigger at CareCloud, we can never lose sight of our entrepreneurial roots.
After the keynote, I headed off to the Healthcare Technology panel. On the panel, I was joined by HCIT folks from Activate Networks, athenahealth, HealthTap, and Operating Analytics. Our panel was moderated by Zen Chu, serial healthcare entrepreneur and founder of MIT’s H@cking Medicine program (who earlier in the day, told me about a startup he recently invested in called Figure1 — think of it as a Pinterest for doctors).
The 50-minute discussion focused on the future of healthcare, from the impact of reform to emerging business models and trends in HCIT investing. As I think back on the panel and dozens of conversations throughout the day, a few things stood out:
1) Big data’s a big deal: Our panel immediately jumped into big data, with one of the more interesting discussions around what’s needed to reach the promised land called population health. For me, it’s about starting with a platform that can easily house both patient and claims data. You can’t have one or the other, you need both – especially as providers take more financial risk for care delivery.
More critically, as you build analytics on top of that, the platform needs to be scalable, have enough horsepower to aggregate and analyze all the information, and is interoperable so you can bring in new data sets from different sources (think genomics or the quantified self). The combination of storing administrative, financial, and clinical data in a powerful, cloud-based system is what we have at CareCloud today and in my view, is a critical enabler for big data going forward.
2) Selling to doctors is hard: During the panel, an audience member (a new HCIT entrepreneur) asked what’s the best way to sell to doctors. As a marketer, we work to connect with practices every day – helping them navigate through the pain of declining reimbursements, while easing their struggle with poorly designed HCIT. In my view, it’s a twofold solution.
First, it’s having a simple, flexible business model like SaaS-based pricing that makes finances easier on practices. Secondly, it’s developing products with “design thinking” from the start. You can build all the Meaningful Use features into your EHR, but if you’re making the doctor’s life harder and she can’t go home to see her family, you’ve failed. Usability has always been an obsession with us at CareCloud, and that’s why I’m so encouraged by the great work of our product teams, led by Edwin Miller, to make the fastest, most user-friendly HCIT solutions out there.
3) Engaging patients is even harder: Throughout the day, there was a lot of buzz about wearable devices like FitBit, mobile health apps like Ginger.io, and physician networks like HealthTap. While the growth of these tools is exciting, it made me realize how siloed all data is and how hard it will be to get patients to take action (I, for one, don’t walk an extra mile when Jawbone Up tells me I’ve hit less than 10,000 steps on any day).
Perhaps it’s linking all this disparate data into a patient portal so it reaches doctors and EHRs, incentivizing doctors on care planning (not just care delivery), or simply having patients pay a greater share of their healthcare spend. However, in my view, a combination of integration and incentives are required to reduce the physician/patient asymmetry.
