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Medicare Advantage Is a Superior Program (Part two)

By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last week arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). Here’s a longer exposition of his argument. We published part one last week so please read that first. This is part two – Matthew Holt

Medicare Advantage is better for the underserved

The African American and Hispanic communities who were particularly hard hit by those conditions and by the Covid death rates have been enrolling in significant numbers in Medicare Advantage plans.

The sets of people who were most damaged by Covid have chosen in disproportional numbers to be Medicare Advantage members. Currently 51 percent of the African Americans on Medicare are in Medicare Advantage plans and more than 60 percent of the Hispanic Medicare members will be on Medicare Advantage this year.

That disproportionate enrollment in Medicare Advantage surprises some people, but it really should not surprise anyone because the Plans have made special,  direct, and inclusive efforts to be attractive to people with those sets of care needs and have delivered better care and service than many of the new enrollees have ever had in their lives. 

The Medicare Advantage plans have language proficiency support competencies, and language requirements and capabilities that clearly do not exist anywhere for fee-for-service Medicare care sites. A combination of team care,  language proficiency, and significantly lower direct health care costs for each member has encouraged that pattern of enrollment as well.

The $1600 savings per person has been a highly relevant factor as more than twice as many of the lowest income Medicare members — people who make less than $30,000 a year — are now enrolled in Medicare Advantage plans.

Medicare Advantage’s critics tend to explicitly avoid discussing those enrollment patterns, and some of the most basic critics actually shamelessly say, with what must be at least unconscious malicious intent in various publications and settings, that the Medicare Advantage demographics for both ethnicity and income levels are a clone for standard Medicare membership. Those critics have said that  there is nothing for us to learn or see from any enrollment patterns or care practices based on those sets of issues.

Many people who discuss Medicare Advantage in media and policy settings generally do not focus on or even mention the people in our population who most need Medicare Advantage — the 4 million people who are now enrolled in the Special Needs Plans.

Special Needs Plans for Dual Eligibles

The Special Needs Plans take care of low-income people who have problematic levels of care needs and who very much need better care.

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What a Waste of a Healthcare System

By KIM BELLARD

An essay in Aeon had me at the title: The Waste Age.  The title was so evocative of the world we live in that I almost didn’t need to read further, but I’m glad I did, and I encourage you to do the same.  Because if we don’t learn to deal with waste – and, as the author urges, design for it – our future looks pretty grim.

Healthcare included.

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Medicare Advantage Is a Superior Program (Part one)

By GEORGE HALVORSON

Former Kaiser Permanente CEO George Halvorson has written on THCB on and off over the years, most notably with his proposal for Medicare Advantage for All post-COVID. He wrote a piece in Health Affairs last week arguing with the stance of Medicare Advantage of Don Berwick and Rick Gilfillan (Here’s their piece pt1, pt2). Here’s a longer exposition of his argument. We are publishing part one today with part two coming soon – Matthew Holt

The evidence for Medicare Advantage being a superior program compared to standard fee-for-service Medicare is so overwhelming that anyone who cares about actual Medicare Patients or who cares about the financial future of Medicare should be strongly supporting having as many people as possible enrolled in that program as soon as we can effectively make that happen.

Compared to fee-for-service Medicare, Medicare Advantage has better benefits.

Compared to fee-for-service Medicare, Medicare Advantage has a better tool kit at multiple levels.

Medicare Advantage has team care, connected care, and electronically supported care processes — and we know beyond any debate or dispute that those advantages exist for Medicare Advantage over standard fee-for-service Medicare because fee-for-service Medicare does not pay for those sets of services and literally labels it billing fraud if a caregiver who provides team care in a patients home to prevent a congestive heart failure crisis or to keep a life threatening and function impairing asthma attack from happening sends a bill to standard Medicare for those services.

The superiority of Medicare Advantage is beyond question.

Standard fee-for-service Medicare has no quality care processes, no quality reports and no quality standards or expectations at all. Standard Medicare actually has absolutely no quality data and does not hold any provider accountable for the quality of the care they deliver.

Medicare Advantage has an extensive quality agenda and tracks more than 40 categories of quality and service at the plan level. Medicare Advantage plans build continuously improving programs around those Five-Star priorities and measures, and we know from our current reporting that even during Covid, the percentage of Medicare Advantage patients with cardiovascular disease who are currently on statin therapy went up from 80.86% of patients a year ago to 83.36% this year.

The ratings by the Medicare Advantage members for customer service by their plans went from 90.56% a year ago to 90.87% this year.

That is not a big improvement but having satisfaction numbers that start out that high actually go up during Covid days is an accomplishment and it is one of the reasons why we should be encouraging people to join the plans and its why fee-for-service Medicare is a measurably inferior approach for so many people.

Standard Medicare does not have a clue about who is getting their statin Medications and they officially don’t care.

In fact, some of the fee-for-service Medicare doctors and care sites who are paid only by the piece for care from the standard Medicare program actually often make more money when care fails, because when a patient has a major asthma crisis or a congestive heart failure crisis, that negative outcome for a patient can generate multiple medical fees and it can too often trigger a $10,000–$20,000 total additional cash flow to the caregivers whose care sites failed that patient by not helping improve the health of the patient before the crisis was triggered.

Why is Medicare Advantage’s purchasing system better?

Medicare Advantage plans are paid by Medicare by the month for each patient and they are not by the piece for each item of care.

Because Medicare Advantage plans are paid by the month for each patient, and must, by contract, provide complete care to each patient, it makes extremely good sense for the plans to help patients in ways that prevent asthma attacks and that prevent congestive heart failure crisis, and that avoid and help reduce the levels of blindness and amputations for their diabetic patients that can too easily happen to those patients if you don’t manage and guide that care.

The Medicare Advantage approach for all of those categories of care is obviously far better for the patients than the fee-for-service Medicare inadequacies in care.

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My 22 Oldest Jokes and Why They Still Matter in 2022

By IAN MORRISON

I have been studying American healthcare for more than 40 years and I have assembled a large number of one-liners over the years. As we enter 2022, I thought I’d share my 22 oldest jokes and why they still matter. 

Coming to America 

  1. I grew up in Glasgow, Scotland.  In Glasgow, healthcare is a right, carrying a machine gun is a privilege. America got it the wrong way round. 

Gun violence continues to ravage the United States. We have more guns than people. Kids get gunned down in school playgrounds and classrooms routinely. It happened once in Dunblane, Scotland in 1996 when a local shopkeeper walked into Dunblane Primary School and opened fire, killing 16 5- and 6-year-olds and their 45-year-old teacher.  It so galvanized public opinion, according to Smithsonian Magazine:  “By the end of 1997, Parliament had banned private ownership of most handguns, including a semi-automatic weapons ban and required mandatory registration for shotgun owners”. 

Last time I looked, gun violence was the second leading cause of death in children in the US.  In America when we have mass shootings all we get are thoughts and prayers. 

And when it comes to healthcare as a right, even if we Build Back Better, it won’t be a right for millions of American residents, especially those who are undocumented. 

  1. I am a Scottish Canadian Californian which gives me a unique perspective on healthcare (and all things to do with healthcare, including death and dying) because the Scots see death as imminent, Canadians see death as inevitable, and Californians see death as optional. 

This is one of my oldest jokes and it remains true.  In Silicon Valley, where I live, my affluent VC friends want to live forever and are working out and taking supplements to achieve that. In contrast, my British friend Dr. Richard Smith (former Editor of the BMJ) is sitting on the Lancet Commission on the Value of Death.  Enough said. 

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“Playing Doctor” – A Cautionary Tale From Health IT Pioneers.

By MIKE MAGEE

Warner Vincent Slack, MD, a pioneer of medical informatics, was a Professor of Medicine at Harvard Medical School in the Division of Clinical Informatics. When he died in 2018 at age 85, his memoriam read:

“For over 50 years, Dr. Slack conducted pioneering research on the use of computers in the medical world and was one of the founders of medical informatics. His goal was to empower both doctors and patients by improving the communication between them.”

Followers of Dr. Slack have labored hard over the past half-century to design solutions that will strengthen rather than weaken the bonds of the patient-physician relationship. But as he suggested at multiple points throughout his career, this goal becomes exponentially more difficult if politicians are allowed to “play doctor” with citizens’ lives.

His awareness of the fallout of the Terri Schiavo “right to die” case, beginning a dozen years after his seminal publication of  “Patient Power: A Patient Oriented Value System”, likely cast a long shadow on his optimistic vision. The case spanned 15 years, as it rode the poor health and disability of one unfortunate woman literally into her grave with devastating consequences for all concerned. 

As the Supreme Court readies itself to serve up opinions in the Texas vigilante and Mississippi abortion cases, the Schiavo case remains a cautionary tale that deserves a careful review. Here’s a quick summary:

  • Theresa Marie Schindler was born in a Philadelphia suburb on December 3, 1963.
  • Terri married her husband, Michael in 1984 and moved to Florida to be close to her parents. 
  • On February 25, 1990, suffering from an eating disorder, she collapsed in the lobby of their apartment, was resuscitated, and hospitalized.
  • Her husband, Michael, was made legal guardian on June 18, 1990. Two physicians independently declared her in a “permanent vegetative state.” A gastric feeding tube was inserted.
  • In mid-1993, Michael signed a Do Not Resuscitate (DNR) order.
  • In May 1998, he filed a petition to remove the feeding tube.
  • The parents challenged the removal in court and lost. The tube was finally removed on April 24, 2001.
  • The parents charged Michael Schiavo with perjury, and a judge ordered the tube reinserted 2 days later.
  • On September 17, 2003,  the appellate judge ordered the feeding tube removed for a second time.
  • Operation Rescue/Right to Life extremist Randall Terry began daily public demonstrations at the care facility.
  • The Florida legislature passed “Terri’s Law”, allowing Gov. Jeb Bush to order the feeding tube surgically reinserted for the third time.
  • On May 5, 2004, “Terri’s Law” was declared unconstitutional.
  • Senator Mel Martinez’s (R-FL) political career was damaged irreparably when memo’s revealed he played politics with the issue.
  • Senator Bill Frist’s hopes for the presidency went up in smoke on March 17, 2005, when he declared on the Senate floor, “I question it (vegetative state) based on a review of the video footage which I spent an hour or so looking at last night in my office.”
  • President Bush transferred the case to Federal Courts. The Federal Court agreed with prior State Court Appeals.
  • Terri Schiavo’s feeding tube was removed a final time on March 24, 2005. She died at a Pinellas Park hospice on March 31, 2005.
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The Eisenhower Principle

By KIM BELLARD

I’ve finally come to understand why the U.S. healthcare system continues to be such a mess, and I have President Dwight Eisenhower to thank.

I’ve been paying close attention to our healthcare system for, I hate to admit, over forty years now. It has been a source of constant frustration and amazement that – year after year, crisis after crisis – our healthcare system doesn’t get “fixed.” Yes, we make some improvements, like ACA, but mostly it continues to muddle along.

Then I learned about President Eisenhower’s approach to problems:

That’s it!  All these smart people, all these years; they didn’t know how to solve the problem that is our healthcare system, so they all took the Eisenhower approach: enlarge the problem.  Let our healthcare system get so bad that not addressing it no longer is possible.

If, indeed, there is such a point.

The actual Eisenhower quote is more nuanced than the above version. It was:

Whenever I run into a problem I can’t solve, I always make it bigger. I can never solve it by trying to make it smaller, but if I make it big enough, I can begin to see the outlines of a solution.

I guess we’re not yet at the point when the outlines of a solution are clear (Bernie Sanders notwithstanding). 

Instead, we’ve been chipping away at the problem, trying to make it smaller. For example:

  • Employer-sponsored health insurance tax preference (WWII)
  • Hill-Burton Act (1946)
  • Medicare/Medicaid (1965)
  • Federal HMO Act (1973)
  • Stark Physician Self-Referral Law (1989)
  • DGRs (1983) & RBRVS (1992)
  • CHIP (1997)
  • Medicare Modernization Act (2003)
  • Affordable Care Act (2010)
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Matthew’s health care tidbits: Drug prices

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

For my health care tidbits this week, I am going to talk drug pricing. Anyone who gets basically any health policy newsletter has seen some of the cash PhRMA has splashed trying to make it seem as though the American public is terrified of drug price controls. But as Michael Millenson on a recent THCB Gang pointed out, when Kaiser Health News asked the question in a rational way, those PhRMA supported numbers don’t hold. 85% of Americans want the government to intervene to reduce drug prices.

Big pharma whines about innovation and how they need high prices to justify R&D spending but health care insiders know two things. First, for ever Big Pharma has spent about twice as much on sales and marketing as it’s spent on R&D. This was true when I first started in health care thirty years ago and it’s still true today. Second, the “R” done by big pharma is resulting in fewer breakthrough drugs per $$ spent now compared to past decades. Which means that they should be increasing that share spent on R&D and need to improve the “R” process. But that’s not happening.

Finally, pharma is very good at increasing prices of branded products and extending their patent protection. Lots of dirty games go on here. Look into it and you can expect a lot of discussion about insulin pricing or discover how Humira is still raking in $16bn a year in the US, despite the fact its original patent expired in 2018. With 85% of the American public in favor, you’d think then that a Democratic Congress would leap at the change to pass a bill that might save the taxpayer $50bn a year in drug costs. But of course that’s not going to happen. There is about $30bn a year in savings in the House version of Build Back Better that passed last week, but there’s little chance of much of that being in the Senate version given Joe Manchin’s daughter’s role running a drug company, and Krysten Sinema being a recent recipient of PhRMA’s largesse. And that’s assuming any version of #BBB gets through the Senate.

Instead hope something small happens to help desperate patients, and wonder how we ended up in a political system that apparently disregards what 85% of the public wants.

The Kids Aren’t Alright

By KIM BELLARD

America, like most cultures, claims to love and value children, but, gosh, the reality sure seems very different. Three recent reports help illustrate this: The Pew Research Center’s report on the expectation of having children, Claire Suddath’s searing look at the childcare industry on Bloomberg, and a UNICEF survey about how young people, and their elders, view the future.   

It’s hard to say which is more depressing.

———

Pew found that the percentage of non-parents under 50 who expect to have children jumped from 37% in 2018 to 44% in 2021. Current parents who don’t expect to have more children edged up slightly (71% to 74%). The main reason given by childless adults for not wanting children was simply not wanting children, cited by 56% of those not wanting children. Among those who gave a reason, medical and financial reasons were cited most often. Current parents were even more likely – 63% – to simply say they just didn’t want more.

This shouldn’t come as a huge surprise. Earlier this year the Census Bureau reported that the birthrate in America dropped for the sixth consecutive year, the largest percentage one year drop since 1965 and the lowest absolute number of babies since 1979. It’d be easy to blame this on the pandemic, but, as sociologist Phillip N. Cohen told The Washington Post: “It’s a shock but not a change in direction.” 

In many ways, having children seems like ignoring everything that’s going on. We have a climate change/global warming crisis that threatens to wreak havoc on human societies, we’re still in the middle of a global pandemic, and our political/cultural climate seems even more volatile than the actual climate. One Gen Xer told The New York Times: “As I think of it, having a child is like rolling dice with the child’s life in an increasingly uncertain world.”

Yikes.

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988: A New Lifeline for Mental Health Emergencies

By BEN WHEATLEY

Miles Hall, a 23-year-old Black man experiencing a psychotic episode, was shot and killed by police after 911 received calls of a disturbance in his Walnut Creek, California neighborhood. His mother Taun Hall had taken steps to warn the local police that her son had been diagnosed with schizoaffective disorder and that he might be prone to mental health crises. She believed she had done enough to ensure that, in the event of a crisis, her son would be treated with care. But when the crisis came, authorities viewed Miles’ behavior through the lens of public safety, not through the lens of mental health, and it cost him his life. 

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Healthcare Not a Part of the US Inflation Surge: Who Knew?

By JEFF GOLDSMITH

When I first appeared in The Health Care Blog fourteen long years ago, it was to decry the policy community’s obsessive search for bad news about the health system: https://thehealthcareblog.com/blog/2007/10/03/the-perpetual-health-care-crisis-by-jeff-goldsmith/. So while we struggled with the COVID pandemic, we continued hearing regularly about pharmaceutical price gouging, anti-competitive hospital mergers, bad labor relations, and provider burnout.  Thus, we can expect to hear nothing whatsoever about the failure of the health system to participate in the current outburst of inflation in the US economy.

The Washington think tank Altarum Institute tracks such things, and in its November 16 report https://altarum.org/sites/default/files/uploaded-publication-files/SHSS-Price-Brief_November_2021.pdf, we learn that healthcare prices rose by an annualized rate of just 2% in October 2021 compared to the Consumer Price Index’s 6.2% and the Producer Price Index’s 8.6%. Altarum commented that this was “surprising given that  many of the same factors impacting economywide  prices (labor shortages, supply chain issues, and increased demand for economywide services) would be expected to impact health care as well.”  

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