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Category: Health Policy

A Letter to Ms. Judy Faulkner & Mr. Tommy Thompson

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By GRACE CORDOVANO PhD, BCPA

Being a patient or a carepartner can be a lonely, powerless place.

There’s no high powered legal or lobbying team to help support you in your or your loved one’s health care journey. There’s no PR team at your beck and call. There’s no advisory board, no executive committee, no assistants, no chatbots or AI-powered technology coming to the rescue. There’s no funding or a company sponsoring your efforts.

There’s no course in how to be a professional patient or carepartner.

There’s no one there in the stillness and dark of the night, when you are in the quiet of your thoughts, the privacy of your personal space, where there are fleeting moments that you don’t have to be strong and courageous. There is no one there to console you, support you as you lay there willing to make a deal with the devil for the slightest glimmer of hope, the slightest bit of clarity, or slightest bit of peace.

As a the carepartner to a loved one who is sick or disabled, many wouldn’t second guess charging head first through a thousand wielded swords if it meant a hope or a cure.

As an advocate, the majority of the work you do is self-created, self-supported, and unpaid. A calling. An undeniable, magnetic force that pulls you in because you cannot turn a blind eye no matter how hard you try. Because you cannot bear witness to human suffering and not do anything. Because you’ve been there and you can relate to another’s pain, grief, and sense of hopelessness and it is unacceptable to not help ease the heaviness of another’s burden.

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Will Medicare Advantage (MA) Startup Plans Be The Future?

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By ANDY MYCHKOVSKY

Would it blow your mind if only five startup health plans interested in Medicare Advantage (MA) have collectively raised over $3.9 billion in private funding to-date? Well, readers, that is the reality. Now I know there are some skeptics out in the healthcare ecosystem, so I’m here to break down some of the investment thesis. Not going to necessarily defend, but explain some reasons why you should love and hate these investments. Let’s start with who raised these mind-boggling sums of money. The five startups are Oscar Health, Bright Health, Clover Health, Devoted Health, and Alignment Healthcare.

  • Oscar Health has raised $1.3 billion
  • Bright Health has raised $1.1 billion
  • Clover Health has raised $925 million
  • Devoted Health has raised $362 million
  • Alignment Healthcare has raised $240 million

I think it’s safe to say that the MA insurance market (also known as Medicare Part C) has captured the imagination of the venture capital and private equity community. The changing demographic trends of an aging baby boomer population, the increased selection of MA plans versus traditional Medicare fee-for-service (FFS), and the opportunity of technology-first MA startup plans to better reduce administrative fees (“Administrative Loss Ratio” or “ALR”) and control medical spend (“Medical Loss Ratio” or “MLR”) seems too good to pass up. If you were going to start a health plan, of all the lines of business you could be focused on, MA has highest profit margins, growing population, and better potential to impact patient spend and manage chronic diseases. It is certainly harder than writing the previous statement, but there are some real benefits versus the traditional commercial or Medicaid managed care.

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Your Wealth is Your Health

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By KIM BELLARD

We’ve been spending a lot of time these past few years debating healthcare reform.  First the Affordable Care Act was debated, passed, implemented, and almost continuously litigated since.  Lately the concept of Medicare For All, or variations on it, has been the hot policy debate.  Other smaller but still important issues like high prescription drug prices or surprise billing have also received significant attention.

As worthy as these all are, a new study suggests that focusing on them may be missing the point.  If we’re not addressing wealth disparities, we’re unlikely to address health disparities.  

It has been well documented that there are considerable health disparities in the U.S., attributable to socioeconomic status, race/ethnicity, gender, even geography, among other factors.  Few would deny that they exist.  Many policy experts and politicians seem to believe that if we could simply increase health insurance coverage, we could go a long way to addressing these disparities, since coverage should reduce financial burdens that may be serving as barriers to care that may be contributing to them.

Universal coverage may well be a good goal for many reasons, but we should temper our expectations about what it might achieve in terms of leveling the health playing field.

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Health Data Outside HIPAA: Simply Extending HIPAA Would Be a #FAIL

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Vince Kuraitis
Deven McGraw

By DEVEN McGRAW and VINCE KURAITIS

This piece is part of the series “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?” which explores whether it’s possible to advance interoperability while maintaining privacy. Check out other pieces in the series here.

Early in 2019 the Office of the National Coordinator for Health IT (ONC) and the Centers for Medicare and Medicaid Services (CMS) proposed rules intended to achieve “interoperability” of health information.

Among other things, these proposed rules would put more data in the hands of patients – in most cases, acting through apps or other online platforms or services the patients hire to collect and manage data on their behalf. Apps engaged by patients are not likely covered by federal privacy and security protections under the Health Insurance Portability and Accountability Act (HIPAA) — consequently, some have called on policymakers to extend HIPAA to cover these apps, a step that would require action from Congress.

In this post we point out why extending HIPAA is not a viable solution and would potentially undermine the purpose of enhancing patients’ ability to access their data more seamlessly:  to give them agency over health information, thereby empowering them to use it and share it to meet their needs.

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Will Your Health Plan Tell You That It Can Save Your Life?

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By MICHAEL MILLENSON

At kitchen tables everywhere, ordinary Americans have been grappling with the arcane language of deductibles and co-pays as they’ve struggled to select a health insurance plan during “open enrollment” season.

Unfortunately, critical information that could literally spell the difference between life and death is conspicuously absent from the glossy brochures and eye-catching websites.

Which plan will arrange a consultation with top-tier oncologists if I’m diagnosed with a complex cancer? Which might alert my doctor that I urgently need heart bypass surgery? And which plan will tell me important information such as doctor-specific breast cancer screening rates?

According to Matt Eyles, president and chief executive officer of America’s Health Insurance Plans (AHIP), insurers over the last decade have made a “dramatic shift” to focus more on consumers.  That shift, however, has yet to include giving members the kind of detailed information available to corporate human resources managers and benefits consultants (one of my past jobs).

What’s at stake could be seen at a recent AHIP-sponsored meeting in Chicago on consumerism. Rajeev Ronaki, chief digital officer for Anthem, Inc., explained how the giant insurer is using artificial intelligence to predict a long list of medical conditions, including the need for heart bypass surgery. Information on individual patients is passed on to clinicians.

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Patient-Directed Uses vs. The Platform

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By ADRIAN GROPPER, MD

This piece is part of the series “The Health Data Goldilocks Dilemma: Sharing? Privacy? Both?” which explores whether it’s possible to advance interoperability while maintaining privacy. Check out other pieces in the series here.

It’s 2023. Alice, a patient at Ascension Seton Medical Center Austin, decides to get a second opinion at Mayo Clinic. She’s heard great things about Mayo’s collaboration with Google that everyone calls “The Platform”. Alice is worried, and hoping Mayo’s version of Dr. Google says something more than Ascension’s version of Dr. Google. Is her Ascension doctor also using The Platform?

Alice makes an appointment in the breast cancer practice using the Mayo patient portal. Mayo asks permission to access her health records. Alice is offered two choices, one uses HIPAA without her consent and the other is under her control. Her choice is:

  • Enter her demographics and insurance info and have The Platform use HIPAA surveillance to gather her records wherever Mayo can find them, or
  • Alice copies her Mayo Clinic ID and enters it into the patient portal of any hospital, lab, or payer to request her records be sent directly to Mayo.

Alice feels vulnerable. What other information will The Platform gather using their HIPAA surveillance power? She recalls a 2020 law that expanded HIPAA to allow access to her behavioral health records at Austin Rehab.

Alice prefers to avoid HIPAA surprises and picks the patient-directed choice. She enters her Mayo Clinic ID into Ascension’s patient portal. Unfortunately, Ascension is using the CARIN Alliance code of conduct and best practices. Ascension tells Alice that they will not honor her request to send records directly to Mayo. Ascension tells Alice that she must use the Apple Health platform or some other intermediary app to get her records if she wants control.  

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Lower Health Insurance Premiums Sound Like Great News – But It’s Only Part Of the Story

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By A. MARK FENDRICK, MD

It’s great news to read headlines that the average health-insurance premium will drop by 4% next year in the 38 states using federal Obamacare exchanges. As millions of Americans entered open enrollment this year to choose their health insurance plans, it is important to remember that premiums are only one of the ways that we pay for our medical coverage. 

In many plans lower premiums (paid by everyone) often mean a higher deductible — or paying more out-of-pocket before insurance coverage kicks in. This burden is paid only by those who use medical care services.

Deductibles are rising, and so is the number of Americans enrolled in so-called high-deductible health plans (HDHPs). Thus, more people with health insurance are being asked to pay full price for all their care, regardless of its clinical value. Although it may be better for many people with significant medical needs (and less disposable income) to avoid plans with high deductibles, more and more people who receive health insurance through their employer no longer have a choice except to choose a plan with hefty costs in addition to premiums.

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The Lynne Chou O’Keefe Fallacy

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By MATTHEW HOLT

Rob Coppedge and Bryony Winn wrote an interesting article in Xconomy yesterday. I told Rob (& the world) on Twitter yesterday that it was good but wrong. Why was it wrong? Well it encompasses something I’m going to call the Lynne Chou O’Keefe Fallacy. And yes, I’ll get to that in a minute. But first. What did Rob and Bryony say?

Having walked the halls and corridors and been deafened by the DJs at HLTH, Rob & Bryony determined why many digital health companies have failed (or will fail) and a few have succeeded. They’ve dubbed the winners “Digital Health Survivors.” And they go on to say that many of the failures have been backed by VCs who don’t know health care while the companies they’ve invested in have “product-market fit problems, sales traction hiccups, or lack of credible proof points.”

What did the ” Survivors” do? They have:  

“hired health care experts, partnered effectively, and have even co-developed their models alongside legacy players. Many raised venture capital from strategic corporate investors who have helped them refine their product, accelerate channel access, and get past the risk of “death by pilot.”

Now it won’t totally shock you to discover that Rob heads Echo Health Ventures, the joint VC fund from Cambia Heath Solutions (Blues of Oregon) & BCBS of N. Carolina, and Bryony runs innovation at BCBS of N. Carolina. So they may be a tad biased towards the strategic venture = success model. But they do have a point. Many but not all of their portfolio are selling tools and services to the incumbents in health care, which mostly includes health plans, hospitals and pharma.

And now we get to the Lynne Chou O’Keefe fallacy. (You might argue that fallacy is the wrong term, but bear with me).

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Maternal Mortality – Separating Signal from Noise

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By AMEYA KULKARNI, MD

When Samuel Morse left his New Haven home to paint a portrait of the Maquis du Lafayette in Washington DC, it was the last time he would see his pregnant wife. Shortly after his arrival in Washington, his wife developed complications during childbirth. A messenger took several days on horseback to relay the message to Mr Morse. Because the trip back to New Haven took several more, his wife had died by the time he arrived at their home.  So moved was he by the tragedy of lost time that he dedicated the majority of the rest of his life to make sure that this would never happen to anyone again. His subsequent work on the telegraph and in particular the mechanism of communication for the telegraph resulted in Morse code – the first instantaneous messaging system in the world.

Mr Morse’s pain is not foreign to us in the 21st century. We feel the loss of new mothers so deeply that, when earlier this year new statistics on the rate of maternal death were released and suggested that American women died at three times the rate of other developed countries during child birth, doctors, patient advocates, and even Congress seemed willing to move heaven and earth to fix the problem. As someone who cares for expectant mothers at high risk for cardiovascular complications, I too was moved. But beyond the certainty of the headlines lay the nuance of the data, which seemed to tell a murkier story.

First at issue was the presentation of the data. Certainly, as a rate per live births, it would seem that the United States lagged behind other OECD countries – our maternal mortality rate was between 17.2 and 26.4 deaths per 100,000 live births, compared to 6.6 in the UK or 3.7 in Spain. But this translated to approximately 700 maternal deaths per year across the United States (among approximately 2.7 million annual births). While we would all agree that one avoidable maternal death is one too many, the low incidence means that small rates of error could have weighty implications on the reported results. For instance, an error rate of 0.01% would put the United States in line with other developed countries.

Surely, the error rate could not account for half the reported deaths, right? Unfortunately, it is difficult to estimate how close to reality the CDC reported data is, primarily because the main source data for maternal mortality is a single question asked on the application for death certificates. The question asks whether the deceased was pregnant at the time of death, within 42 days of death, or in the 43 to 365 days prior to death. While pregnancy at the time of death may be easy to assess, the latter two categories are subject to significantly more error.

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Guerilla Billing – Missing the Gorilla in the Midst

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By ANISH KOKA, MD

No one likes getting bills. But there is something that stinks particularly spectacularly about bills for healthcare that arrive despite carrying health insurance. Patients pay frequently expensive monthly premiums with the expectation that their insurance company will be there for them when illness befalls them.

But the problem being experienced by an increasing number of patients is going to a covered (in-network) facility for medical care, and being seen by an out-of-network physician. This happens because not all physicians working in hospitals serve the same master, and thus may not all have agreed to the in-network rate offered by an insurance company.

This is a common occurrence in medicine. At any given time, your local tax-exempt non-profit hospital is out of network of some low paying Medicaid plan or the other.

In this complex dance involving patients, insurers and doctors, Patients want their medical bills paid through premiums that they hope to be as low as possible, Insurers seek to pay out as little of the premium dollars collected as possible, and Doctors want to be paid a wage they feel is commensurate to their training and accumulated debt.

Insurers act as proxies for patients when negotiating with the people that actually deliver healthcare – doctors. Largely, the system works to funnel patients to ‘covered’ doctors and hospitals. Patients that walk into an uncovered facility are quickly redirected. But breakdowns happen during emergencies.

There are no choices to make for patients arriving unconscious or in distress to an emergency room. It suddenly becomes very possible to be seen by an out of network physician, and depending on the fine print of the insurance plans selected, some or none of these charges may be covered.

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