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Category: Health Policy

The Sweet Spot of Health Care Cost Containment

BY BEN WHEATLEY

As health care continues to move in the direction of unaffordability, policy makers are considering a range of options to bring down health care costs. The Health Affairs Committee on Health Care Spending and Value has identified four broad areas for reform, including administrative savings, price regulation and supports for competition, spending growth targets, and value-based payment. These measures appropriately target health care’s supply side and the excesses that exist in the health care system.

In this blog, I would like to highlight another avenue for savings: one that focuses on the demand side of the equation. It is possible to reduce health care expenditures by reducing the demand for care. This is distinct from rationing, which is the denial of needed care. I’m referring to genuine health improvements that make health care less necessary in the first place. This type of health improvement is the sweet spot of health care cost containment, benefiting both patients and purchasers.

In a previous blog, I posed the question: in an ideal world, how much would we spend on health care? I posited that in a perfect world, we would spend zero on health care because no one would be sick. While such a perfect world may be unachievable, having the goal in mind can serve to guide our way in the present moment—like entering a destination into GPS.  

Measures that promote genuine health improvement can alleviate the burden of illness while at the same time reducing the cost of care. They move us in the direction we want to go. In this blog I provide several such examples.

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No, the Poor Don’t Always Have to Be With Us

BY KIM BELLARD

OK, for you amateur (or professional) epidemiologists among us: what are the leading causes of death in the U.S.?  Let’s see, most of us would probably cite heart disease and cancer.  After that, we might guess smoking, obesity, or, in recent years, COVID.  But a new study has a surprising contender: poverty.   

It’s the kind of thing you might expect to find in developing countries, not in the world’s leading economy, the most prosperous country in the world. But amidst all that prosperity, the U.S. has the highest rates of poverty among developed countries, which accounts in no small part for our miserable health outcomes.  The new data on poverty’s mortality should come as no surprise.

The study, by University of California Riverside professor David Brady, along with Professors Ulrich Kohler and Hui Zheng, estimated that persistent poverty – 10 consecutive years of uninterrupted poverty – was the fourth leading cause of death, accounting for some 295,000 deaths (in 2019). Even a single year of poverty was deadly, accounting for 183,000 deaths.  

“Poverty kills as much as dementia, accidents, stroke, Alzheimer’s, and diabetes,” said Professor Brady. “Poverty silently killed 10 times as many people as all the homicides in 2019. And yet, homicide firearms and suicide get vastly more attention.” 

The study found that people living in poverty didn’t start showing increased mortality until in their 40’s, when the cumulative effects start catching up.  The authors note that these effects are not evenly distributed: “Because certain ethnic and racial minority groups are far more likely to be in poverty, our estimates can improve understanding of ethnic and racial inequalities in life expectancy.”

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Health Tech’s Magic Wand: The Anti-Social Bent of Modern Medicine

BY MIKE MAGEE

In George Packer’s classic 2013 New Yorker article titled “Change the World: Silicon Valley transfers its slogans – and its money – to the realm of politics,” there is a passage worth a careful reread now a decade latter.

Packer shares an encounter with a 20-something techie critiquing his young colleagues who said, “Many see their social responsibility fulfilled by their businesses, not by social or political action. It’s remarkably convenient that they can achieve all their goals just by doing their start-up. They actually think that Facebook is going to be the panacea for many of the world’s problems. It isn’t cynicism—it’s arrogance and ignorance.”

Packer’s assessment at the time was “When financiers say that they’re doing God’s work by providing cheap credit, and oilmen claim to be patriots who are making the country energy-independent, no one takes them too seriously—it’s a given that their motivation is profit. But when technology entrepreneurs describe their lofty goals there’s no smirk or wink.”

Or, as others might say, “They believe their own bull shit.” Where many of us are currently focused on issues of values, fairness and justice, those in the shadows of Silicon Valley see the challenge to be inefficiency and incompetence, and the solution amenable to technologic engineering.

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HHS Again Suspends Disbelief: The Medicaid Program Will Ignore the Greatest Health Threat to Medicaid Beneficiaries

BY DAVID INTROCASO

In May the Centers for Medicare and Medicaid Services (CMS) simultaneously published two proposed Medicaid rules (here and here) intended to improve moreover access and quality.  Both discussed at length the agency’s commitment to “addressing health equity.”  The first sentence in both identified health equity as a Medicaid program priority.  The proposed “ensuring access” rule stated CMS “takes a comprehensive approach to . . . better addressing health equity issues in the Medicaid program.”  CMS went on to state “we are working to advance health equity by designing, implementing, and operationalizing policies and programs” by “eliminating avoidable differences in health and quality of life outcomes experienced by people who are disadvantaged or underserved.”

Nevertheless, CMS’ interest in health equity is entirely performative.  It is impossible to believe the agency is legitimately interested in “eliminating avoidable differences” because leadership is well aware the greatest health equity threat to Medicaid – and Medicare – beneficiaries is the climate crisis.  This is because the most climate vulnerable Americans are Medicaid and Medicare populations.  Yet, the climate crisis is never addressed much less mentioned in either proposed Medicaid rule.  The word “climate” never appears in 291 Federal Register pages. 

This is explained by the fact that despite the Biden administration’s “government-wide approach” approach to “tackle” the climate crisis, HHS has refused to address the threat the climate crisis poses by regulating the healthcare industry’s massive carbon footprint.

Children, 36 percent of whom are Medicaid beneficiaries, are uniquely vulnerable.  Fine respirable particles resulting from fossil fuel combustion are particularly harmful because children breathe more air than adults relative to their body weight.  Research published last year concluded the health effects to the fetus, infant and child include preterm and low-weight birth, infant death, hypertension, kidney and lung disease, immune-system dysregulation, structural and functional changes to the brain and a constellation of behavioral health diagnoses.   

Medicare beneficiaries, already compromised due to higher incidence rates of co-morbidities, are at even greater risk related to arthropod-borne, food-borne and water-borne diseases because the climate crisis can increase the severity of over half of known human pathogenic diseases.  Extreme heat episodes are particularly deadly.  Over the past 20 years heat-related mortality among seniors has increased 54%

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Medicare Advantage Plans Can Leverage Virtual Cardiometabolic Care

By RICHARD FRANK

By relying on virtual cardiometabolic solutions for continuous care, Medicare Advantage can produce better outcomes, curb costs, enhance member satisfaction — and improve Star ratings in the process.

Medicare Advantage is a hot market. Enrollment is steadily climbing and Medicare Advantage (MA) members now make up half the Medicare population. Though members keep rolling in, competition among MA plans is tight and turnover remains high. Nearly 16% of MA members switch plans at least once during their first year, while over a third end up switching by year three. Higher-need Medicare members tend to disenroll altogether, impacting Stars ratings.

On top of fierce competition for members, MA plans struggle with ballooning costs as rates of cardiometabolic conditions like diabetes, obesity, and hypertension persistently rise. It’s hard to overstate what a toll cardiometabolic conditions take on our nation’s seniors — especially since those conditions tend to co-occur and compound with age. We’re long overdue for more innovative solutions.

Poorly managed cardiometabolic conditions are significant drivers of MA medical expense trend and spend, member dissatisfaction, and, by extension, poor Star performance. But increasingly, virtual care companies are starting to turn some of those trends around. MA plans should take note. 

Virtual care provides value-based pricing and cost-saving interventions

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“Sons of Liberty” Flea Into King George’s (or Donald’s) Open Arms.

BY MIKE MAGEE

If there is a silver lining to the Trump assault on decency and civility, it is our majority response to this “stress test” of our Democracy, and the sturdiness (thus far) of our Founders’ vision. 

It was, after all, a long shot when Alexander Hamilton, under the pen name Publius, published Federalist No. 1 on October 27, 1787, writing: “It has been frequently remarked that it seems to have been reserved to the people of this country, by their conduct and example, to decide the important question, whether societies of men are really capable or not of establishing good government from reflection and choice, or whether they are forever destined to depend for their political constitutions on accident and force.”

Two weeks before the Iowa caucus in 2016, Trump himself sided with “force” and signaled a rocky road ahead when he stated in Sioux City, Iowa, that “I could stand in the middle of Fifth Avenue and shoot somebody, and I wouldn’t lose any voters, OK? Its, like, incredible.”

In so doing, he was taking on medieval jurist, Henry de Bracton, who wrote in On the Laws and Customs of England in 1260 that “The king should be under no man, but under God and the law.”

Of course, Trump, while representing our Executive branch, was not acting alone. He was supported by members of our Legislative branch as they successfully stacked the Judicial branch with religious conservatives. The net impact was this past year’s overturning of Roe v. Wade, and a Christian Evangelical legislative windfall (and subsequent political backlash) in multiple Red States across the union.

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Not The Last of Them

By KIM BELLARD

I’m seeing two conflicting yet connected visions about the future. One is when journalist David Wallace-Wells says we might be in for “golden age for medicine,” with CRISPR and mRNA revolutionizing drug development. The second is the dystopian HBO hit “The Last of Us,” in which a fungal infection has turned much of the world’s population into zombie-like creatures.

The conflict is clear but the connection not so much. Mr. Wallace-Wells never mentions fungi in his article, but if we’re going to have a golden age of medicine, or if we want to avoid a global fungal outbreak, we better be paying more attention to mycology – that is, the study of fungi.

We don’t need “The Last of Us” to be worried about fungal outbreaks.  The Wall Street Journal reports:

Severe fungal disease used to be a freak occurrence. Now it is a threat to millions of vulnerable Americans, and treatments have been losing efficacy as fungal pathogens develop resistance to standard drugs. 

“It’s going to get worse,” Dr. Tom Chiller, head of the fungal-disease branch of the Centers for Disease Control and Prevention, warns WSJ.

A new study found that a common yet extremely drug resistant type of fungus — Aspergillus fumigatus – has been found even in a very remote, sparsely populated part of China.  Professor Jianping Xu, one of the authors, points out: “This fungus is highly ubiquitous — it’s around us all the time. We all inhale hundreds of spores of this species every day.”

We shouldn’t be surprised, because fungi tend to spread by spores  In fact, according to Merlin Sheldrake’s fascinating Entangled Life: How Fungi Make Our Worlds, Change Our Minds, and Shape Our Futures, fungi spores are the largest source of living particles in the air. They’re also in the ground, in the water, and in us. They’re everywhere.

That sounds scary, but without fungi, we not only wouldn’t be alive, we never would have evolved.

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Matthew’s health care tidbits: Time to get Cynical

Each time I send out the THCB Reader, our newsletter that summarizes the best of THCB (Sign up here!) I include a brief tidbits section. Then I had the brainwave to add them to the blog. They’re short and usually not too sweet! –Matthew Holt

Plenty of reason to worry about the future of American health care this week. The biggest for-profit hospital chain–HCA–was accused of aggressively pushing patients into hospice care, sometimes in the same room, in order to make their hospitality mortality numbers look better. Most of the leading benefits consulting companies were exposed as taking payments from PBMs–yup, the same organizations their employer clients thought they were negotiating with on their behalf. And one of the biggest names in digital health, Babylon Health, tumbled into destitution, taking billions of dollars with it and leaving uncertain the fate of the medical groups in California it bought less than two years ago. Even the most successful capitalists in health care — United HealthGroup and its fellow insurers — saw their stock fall because apparently outpatient surgery volume is ticking up

On the policy front the malaise is spreading too. The end of the public health emergency (remember Covid?) is being used as an excuse by the old  confederate states to kick people off Medicaid. Georgia and Arkansas appear to be bringing back work requirements, even though I thought CMS has banned them and every study has acknowledged that they are cruel and ineffective. About 20 million people got on to Medicaid during the public health emergency and KFF estimates up to 17 million may be kicked off, while over 1.7 million already have.

Finally an article by Bob Kocher and Bob Wachter in Health Affairs Scholar remins us that big academic medical centers are nowhere near ready for value-based care (VBC). Jeff Goldsmith has been vocal on THCBGang and elsewhere about how VBC is becoming a religion more than a reality. And I remind you that Humana’s MA program is still basically a Fee-For-service program in drag (even though that’s now illegal in their home state). 

I grew up in American health care expecting that eventually a combination of universal insurance mixed with value-based purchasing would lead to a series of tech-enabled companies doing the right thing by patients and making money to boot. With the managed care revolution, the ACA and the boom in digital health all firmly in the rear view mirror, the summer of 2023 is a lesson that you can never be too cynical about health care in America.

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The Truth About Medicare Advantage Saving Medicare

BY GEORGE HALVORSON

We know from the current annual report from the Medicare trustees that Medicare Advantage is saving Medicare, and that Medicare will be a much stronger program as Medicare Advantage continues to grow.

When we look at actual numbers from that report, we see that Medicare Advantage cost Medicare $403.3bn last year.

The report shows that Medicare is growing 6.7% each year in total revenue. We see that Medicare Parts A and B have expense growth that slightly exceeds 8%, and that Medicare Advantage is projected to have expense growth of 4.2% for the year.

That means we’re losing money from the fee-for-service part of the Medicaid program — and that is eating into the Medicare trust fund. We also can see that Medicare Advantage is making a surplus for Medicare, and is increasing the size of the fund.

We know that Medicare Advantage bids against the average cost of Medicare in every county to create the capitation levels for each year. Those bids are typically discounted by 15% (or more) from the average Medicare cost.

Those discounted bids cost Medicare less in actual dollars each month. The Medicare Advantage critics speculate about coding levels for the plans, but the Medicare trust fund doesn’t care about codes.

They only care about actual dollars. When you look at actual dollars, we see that Medicare spent $403.3bn to pay for the coverage with Medicare Advantage plans.

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Revisualizing and Recoding Healthcare

BY KIM BELLARD

Two new books have me thinking about healthcare, although neither is about healthcare and, I must admit, neither of which I’ve yet read. But both appear to be full of ideas that strike me as directly relevant to the mess we call our healthcare system.  

The books are Atlas of the Senseable City, by Antoine Picon and Carlo Ratti, and Recoding America: Why Government Is Failing in the Digital Age and How We Can Do Better, by Jennifer Pahlka.  

Dr. Picon is a professor at The Harvard Graduate School of Design, and Professor Ratti is head of MIT’s Senseable Lab. Drawing on the Lab’s work, they write: “We hope to reveal here an urban landscape of not just spaces and objects, but also motion, connection, circulation, and experience.” I.e. dynamic maps. Traffic, weather, people’s moment-by-moment decisions all change how a city moves and works in real time.

Dr. Picon says

These maps are a new way to apprehend the city, They’re no longer static. Maps provide a way to visualize information. They’re crucial to diagnosing problems. I think they provide a new depth…It’s a little bit like the discovery of the X-ray. You can see things within cities that were not previously accessible. You don’t see everything, but you see things you were not able to see before.

So I wondered: what would a dynamic map of our healthcare system look like?  

I’m telling you, just a map of what happens between drug companies, PBMs, health plans, pharmacies, and patients would open people’s eyes to that particular insanity in our healthcare system.  Now repeat for the millions of other ecosystems in our healthcare system.  If that kind of dynamic mapping — showing all the complexities, bottlenecks, circuitous routes, and redundancies within the system — wouldn’t lead to health care reform, I don’t know what would.

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