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Category: Health Policy

Charting The Economic History of US Health Reform

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By MIKE MAGEE, MD

Adam Gaffney’s recent Boston Review article, “What the Health Care Debate Still Gets Wrong”, a landmark piece that deserves careful reading by all, reaches near perfection in diagnosing our health system malady.

Dr. Gaffney is president of Physicians for a National Health Program, and a co-chair of the Working Group on Single-Payer Program Design, which developed the “Physicians’ Proposal for Single-Payer Health Care Reform.”

A seasoned health policy expert, his article cross-references the opinions and work of a range of health commentators including Atul Gawande, Steven Brill, Sarah Kliff, Elizabeth Rosenthal, Zack Cooper, and Canadian health economist Robert Evans. But his major companion is Princeton health economist, Uwe Reinhardt, whose posthumous book, Priced Out: The Economic and Ethical Costs of American Health Care, was recently published by Princeton University Press.

Gaffney’s affection for Reinhardt is evident as he recounts his desperate upbringing in post-war Germany, challenged by poor living conditions, but made whole by access to health care.  Quoting a 1992 JAMA interview, Reinhardt states, “When we needed medical care, we got it at the local hospital, no questions asked. When you were sick, society was there for you.”

That acknowledgment is not only personal but historically significant, as I outline in my recent book, Code Blue: Inside the Medical Industrial Complex. The services Reinhardt received were part of a new national health care system funded fully by American taxpayers as part of the Marshall Plan. At the very same time, American citizens were denied a national health plan of their own as Truman was effectively branded a supporter of “socialized medicine” by the AMA and a cabal of corporate partners.

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BetterCare for All

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By ROBERT M. HERZOG

The Cure for healthcare isn’t Medicare for All, it’s establishing organizations with complete responsibility for the total care, costs, quality and outcomes for a person.

Discussions of Medicare for All substitute structure for substance. They engender a debate about the trappings of care delivery, administration, and cost, but don’t address the fundamental issue, which is how to provide genuinely better care for people of all ages and economic circumstances.

The premise of Medicare for All is that a single payer will provide better and more cost effective care. But what is really needed is single entity accountability. Whether there are one or many, whether they are public or private, is not as important as that one organization and its people become responsible for the total health and care of an individual and the costs associated with that care. With incentives for doing it well, and penalties for doing it poorly. And an ease of transition for people to move from an entity that doesn’t serve them well to one that does, to maintain the benefits of competition and varied approaches based on differing conditions.

Focusing on Medicare for All promulgate a systemic flaw baked into our health insurance and provider systems. High costs and lower quality can’t just be fixed by a single payer negotiating lower drug prices, nor would providing fewer services mean better care at lower costs. The core problem is exemplified by the invidious arbitrary split in public health insurance between Medicaid and Medicare, with each providing different services spread out among many providers, none of whom have sole responsibility for the complete health of the person.

BetterCare for All need not be a win-lose proposition, of Medicare for All or nothing. The feasibility near term of a one payer system is low, whereas the feasibility of building on existing systems and frameworks to create single system accountability is much higher.

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What Google Isn’t Saying About Your Health Records

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By ADRIAN GROPPER, MD

Google’s semi-secret deal with Ascension is testing the limits of HIPAA as society grapples with the future impact of machine learning and artificial intelligence.

Glenn Cohen points out that HIPAA may not be keeping up with our methods of consent by patients and society on the ways personal data is used. Is prior consent, particularly consent from vulnerable patients seeking care, a good way to regulate secret commercial deals with their caregivers? The answer to a question is strongly influenced by how you ask the questions.

Here’s a short review of this current and related scandals. It also links to a recent deal between Mayo and Google, also semi-secret. A scholarly investigative journalism report of the Google AI scandal with London NHS Foundation Trust in 2016 might be summarized as: the core issue is not consent; it is a conflict of interest at the very foundation of the information governance process. The foxes are guarding the patient data henhouse. When the secrecy of a deal is broken, a scandal ensues.

The parts of the Google-Ascension deal that are secret are likely designed to misdirect attention away from the intellectual property value of the business relationship.

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The Untold Reality of Medical Device Shortages in the U.S.

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Chaun Powell
Soumi Saha

By CHAUN POWELL, MBA and SOUMI SAHA, PharmD, JD

Say the word “shortage” to a healthcare professional and chances are the first thing that will come to mind is drug shortages. With good reason, too – there are more than 100 drugs currently at risk or not readily available for U.S. hospitals, according to the Food and Drug Administration’s (FDA) drug shortage list. 

Shortages don’t just apply to drugs, however, and as 2019 has shown, healthcare providers must become more focused on shortages of the medical device variety. The shutdown of multiple medical device sterilization facilities in 2019 is poised to jeopardize the availability of devices that are critical to routine patient care. On Nov. 6, the FDA is hosting a panel to hear from stakeholders, including hospital epidemiologists and healthcare supply chain experts, on the risks associated with facility shutdowns and potential action steps.

The industry as a whole is in need of meaningful solutions. As taxpayers, patients and key stakeholders in healthcare, we must collaborate to eliminate interruptions to our healthcare supply chain. For those invested in improving healthcare from the inside, this means working across competitive boundaries and borrowing best practices from sister industries as we work to identify the root cause of these issues and provide meaningful and preventative solutions.

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ACCESS Act Points the Way to a Post-HIPAA World

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By ADRIAN GROPPER, MD

The Oct. 22 announcement starts with: “U.S. Sens. Mark R. Warner (D-VA), Josh Hawley (R-MO) and Richard Blumenthal (D-CT) will introduce the Augmenting Compatibility and Competition by Enabling Service Switching (ACCESS) Act, bipartisan legislation that will encourage market-based competition to dominant social media platforms by requiring the largest companies to make user data portable – and their services interoperable – with other platforms, and to allow users to designate a trusted third-party service to manage their privacy and account settings, if they so choose.”

Although the scope of this bill is limited to the largest of the data brokers (messaging, multimedia sharing, and social networking) that currently mediate between us as individuals, it contains groundbreaking provisions for delegation by users that is a road map to privacy regulations in general for the 21st Century.

The bill’s Section 5: Delegation describes a new right for us as data subjects at the mercy of the institutions we are effectively forced to use. This is the right to choose and delegate authority to a third-party agent that can manage interactions with the institutions on our behalf. The third-party agent can be anyone we choose subject to their registration with the Federal Trade Commission. This right to digital representation by an entity of our choice with access to the full range of our direct control capabilities is unprecedented, as far as I know.

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Improving the Affordable Care Act Markets (Part 2)

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By JONATHAN HALVORSON

In a previous post, I described how some features of the Affordable Care Act, despite the best intentions, have made it harder or even impossible for many plans to compete against dominant players in the individual and small employer markets. This has undermined aspects of the ACA designed to improve competition, like the insurance exchanges, and exacerbated a long term trend toward consolidation and reduced choice, and there is evidence it is resulting in higher costs. I focused on the ACA’s risk adjustment program and its impact on the small group market where the damage has been greatest.

The goal of risk adjustment is commendable: to create stability and fairness by removing the ability of plans to profit by “cherry picking” healthier enrollees, so that plans instead compete on innovative services, disease management, administrative efficiency, and customer support. But in the attempt to find stability, the playing field was tilted in favor of plans with long-tenured enrollment and sophisticated operations to identify all scorable health risks. The next generation of risk adjustment should truly even out the playing field by retaining the current program’s elimination of an incentive to avoid the sick, while also eliminating its bias towards incumbency and other unintended effects.

One important distinction concerns when to use risk adjustment to balance out differences that arise from consumer preferences. For example, high deductible plans tend to attract healthier enrollees, and without risk adjustment these plans would become even cheaper than they already are, while more comprehensive plans that attract sicker members would get disproportionately more expensive, setting off a race to the bottom that pushes more and more people into the plans that have the least benefits, while the sickest stay behind in more generous plans whose premium cost spirals upward. Using risk adjustment to counteract this effect has been widely beneficial in the individual market, along with other features like community rating and guaranteed issue.

However, in other cases where risk levels between plans differ due to consumer preferences it may not be helpful. For example, it has been documented that older and sicker members have a greater aversion to change (changing plans to something less familiar) and to constraints intended to lower cost even if they do not undermine benefit levels or quality of care, like narrow networks. These aversions tend to make newer plans and small network plans score as healthier. Risk adjustment would then force those plans to pay a penalty that in turn forces enrollees in the plans to pay for the preferences of others.

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$2 Trillion+ in New Taxes for Single Payer, or $50 Billion to Strengthen ObamaCare? Next Question, Please

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By BOB HERTZ

It is not wise for Democrats to spend all their energy debating Single Payer health care solutions.

None of their single player  plans has much chance to pass in 2020, especially under the limited reconciliation process. In the words of Ezra Klein, “If Democrats don’t have a plan for the filibuster, they don’t really have a plan for ambitious health care reform.”

Yet while we debate Single Payer – or, even if it somehow passed, wait for it to be installed — millions of persons are still hurting under our current system.

We can help these people now!

Here are six practical programs to create a better ACA.

Taken all together they should not cost more than $50 billion a year. This is a tiny fraction of the new taxes that would be needed for full single payer. This is at least negotiable, especially if Democrats can take the White House and the Senate.

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Improving the Affordable Care Act Markets (Part 1)

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By JONATHAN HALVORSON, PhD

With each passing year, the Affordable Care Act becomes further entrenched in the American health care system. There are dreams on both the far left and far right to repeal and replace it with something they see as better, but the reality is that the ACA is a remarkable achievement which will likely outlast the political lifetimes of those opposing it. Future improvements are more likely to tweak the ACA than to start over from scratch.

A critical part of making the ACA work is for it to support healthy, competitive and fair health insurance markets, since it relies on them to provide health care benefits and improve access to care. This is particularly true for insurance purchased by individuals and small employers, where the ACA’s mandates on benefits, premiums and market structure have the most impact. One policy affecting this dynamic that deserves closer attention is risk adjustment, which made real improvements in the fairness of these markets, but has come in for accusations that it has undermined competition.

Risk adjustment in the ACA works by compensating plans with sicker than average members using payments from plans with healthier members. The goal is to remove an insurer’s ability to gain an unfair advantage by simply enrolling healthier people (who cost less). Risk adjustment leads insurers to focus on managing their members’ health and appropriate services, rather than on avoiding the unhealthy. The program has succeeded enormously in bringing insurers to embrace enrolling and retaining those with serious health conditions.

This is something to celebrate, and we should not go back to the old days in which individuals or small groups would be turned down for health insurance or charged much higher prices because they had a history of health issues. However, the program has also had an undesired effect in many states: it further tilted the playing field in favor of market dominant incumbents.

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How are hospitals supposed to reduce readmissions? Part III

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By KIP SULLIVAN, JD

The Medicare Payment Advisory Commission (MedPAC) and other proponents of the Hospital Readmissions Reduction Program (HRRP) justified their support for the HRRP with the claim that research had already demonstrated how hospitals could reduce readmissions for all Medicare fee-for-service patients, not just for groups of carefully selected patients. In this three-part series, I am reviewing the evidence for that claim.

We saw in Part I and Part II that the research MedPAC cited in its 2007 report to Congress (the report Congress relied on in authorizing the HRRP) contained no studies supporting that claim. We saw that the few studies MedPAC relied on that claimed to examine a successful intervention studied interventions administered to carefully selected patient populations. These populations were severely limited by two methods: The patients had to be discharged with one of a handful of diagnoses (heart failure, for example); and the patients had to have characteristics that raised the probability the intervention would work (for example, patients had to agree to a home visit, not be admitted from a nursing home, and be able to consent to the intervention).

In this final installment, I review the research cited by the Yale New Haven Health Services Corporation (hereafter the “Yale group”) in their 2011 report to CMS in which they recommended that CMS apply readmission penalties to all Medicare patients regardless of diagnosis and regardless of the patient’s interest in or ability to respond to the intervention. MedPAC at least limited its recommendation (a) to patients discharged with one of seven conditions/procedures and (b) to patients readmitted with diagnoses “related to” the index admission. The Yale group threw even those modest restrictions out the window.

The Yale group recommended what they called a “hospital-wide (all-condition) readmission measure.” Under this measure, penalties would apply to all patients regardless of the condition for which they were admitted and regardless of whether the readmission was related to the index admission (with the exception of planned admissions). “Any readmission is eligible to be counted as an outcome except those that are considered planned,” they stated. (p. 10) [1] The National Quality Forum (NQF) adopted the Yale group’s recommendation almost verbatim shortly after the Yale group presented their recommendation to CMS.

In their 2007 report, MedPAC offered these examples of related and unrelated readmissions: “Admission for angina following discharge for PTCA [angioplasty]” would be an example of a related readmission, whereas “[a]dmission for appendectomy following discharge for pneumonia” would not. (p. 109) Congress also endorsed the “related” requirement (see Section 3025 of the Affordable Care Act, the section that authorized CMS to establish the HRRP). But the Yale group dispensed with the “related” requirement with an astonishing excuse: They said they just couldn’t find a way to measure “relatedness.” “[T]here is no reliable way to determine whether a readmission is related to the previous hospitalization …,” they declared. (p. 17) Rather than conclude their “hospital-wide” readmission measure was a bad idea, they plowed ahead on the basis of this rationalization: “Our guiding principle for defining the eligible population was that the measure should capture as many unplanned readmissions as possible across a maximum number of acute care hospitals.” (p. 17) Thus, to take one of MedPAC’s examples of an unrelated admission, the Yale group decided hospitals should be punished for an admission for an appendectomy within 30 days after discharge for pneumonia. [2]

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The good, the bad, and the hopeful in new interoperability plans from Washington

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Claudia Williams, Manifest MedEx, Amazon

By CLAUDIA WILLIAMS

Robust exchange of health information is absolutely critical to improving health care quality and lowering costs. In the last few months, government leaders at the US Department of Health and Human Services (HHS) have advanced ambitious policies to make interoperability a reality. Overall, this is a great thing. However, there are places where DC regulators need help from the frontlines to understand what will really work. 

As California’s largest nonprofit health data network, Manifest MedEx has submitted comments and met with policymakers several times over the last few months to discuss these policies. We’ve weighed in with Administrator Seema Verma and National Coordinator Dr. Don Rucker. We’ve shared the progress and concerns of our network of over 400 California health organizations including hospitals, health plans, nurses, physicians and public health teams. 

With the comment periods now closed, here’s a high-level look at what lies ahead: 

CMS is leading on interoperability (good). Big new proposals from the Centers for Medicare and Medicaid Services (CMS) will set tough parameters for sharing health information. With a good prognosis to roll out in final form around HIMSS 2020, we’re excited to see requirements that health plans give patients access to their claims records via a standard set of APIs, so patients can connect their data to apps of their choosing. In addition, hospitals will be required to send admit, discharge, transfer (ADT) notifications on patients to community providers, a massive move to make transitions from hospital to home safe and seamless for patients across the country. Studies show that readmissions to the hospital are reduced as much as 20% when patients are seen by a doctor within the first week after a hospitalization. Often the blocker is not knowing a patient was discharged. CMS is putting some serious muscle behind getting information moving and is using their leverage as a payer to create new economic reasons to share. We love it.

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