By KIP SULLIVAN, JD

In an earlier post, I criticized managed care proponents for promoting concepts defined only by the aspirations of their proponents.  HMO, ACO, “medical home,” and “patient-centered this and that” are examples.

The “public option” (PO) is the latest example of a buzzword defined only by the aspirations of its proponents. The PO, first introduced to the public a decade ago by Jacob Hacker, Democratic presidential candidates and advocates of what would become the Affordable Care Act, has been revived by Democrats over the last five months. [1] Hacker, Hillary Clinton, Barack Obama and others say a PO would reduce premium inflation. But they refuse to define the PO, which makes it impossible to determine whether it could survive, much less reduce premium inflation. It’s not even clear whether proponents are proposing a PO open to all Americans or just to those who shop on the state exchanges established by the Affordable Care Act. The best they can do is say the PO will be “like Medicare.” That’s not a definition. That’s an aspiration.

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By THCB STAFF

THCB would not be possible without the generous support of our corporate supporters. Today’s shout out goes out to the good people at HealthCatalyst, one of our favorite Health IT companies. Visit the HealthCatalyst Knowledge Center for great tutorials, walk-throughs and explainers on value-based care and the Affordable Care Act. You’ll also find online sessions like this week’s highly useful MACRA FAQ.

By THCB STAFF

Speaking of frequently asked questions, THCB will be collecting yours this fall going into the New Year.  Send us (or tweet) your questions about MACRA, value-based care and payment reform and we’ll publish them. While much of our coverage of payment reform centers on the big picture issues around the Affordable Care Act, the what-ifs and the whys and why nots, our readers also want practical advice and insight on how best to manage the transition to this important new payment model.

If you’ve had an experience with an early ACO you’d like to tell us about, feel free to write. You can also post your comments in this place. Be sure to include your organizational affiliation if you’d like credit for your ideas, although anonymous contributions will be accepted as always.  To get started, you can check out the online session on  MACRA Frequently Asked Questions here. Come back to THCB for posts in the weeks to come. 

By RYAN MARLING

Health plan deductibles are on the rise in a big way. Deductibles, or the amount of money members must pay out-of-pocket before their health plans kick in, have soared a whopping 63% over the last five years. This is compared to the modest 19% growth in health plan premiums during the same time period. Rising deductibles represent a shift in who is being exposed to financial risk in healthcare. The burden of the spiraling healthcare cost problem in the United States is being shifted away from insurers and employers and more and more upon the shoulders of individuals and families in the form of out-of-pocket payments.

Insurers construct deductibles into their health plans as tools to prevent members from spending more on healthcare than they truly need. They reason that if members have ‘skin in the game,’ they will prudently shop around for reasonably priced healthcare providers, and not purchase more healthcare goods and services than necessary. Continue reading…

By ANISH KOKA, MD

I was asked to see an unfortunate elderly man – Harry – one afternoon.  He had multiple coronary stents placed for coronary disease over the course of the last ten years, and after presenting with difficulty speaking, was found to have a brain tumor.  The neurosurgeon was hoping I could provide some reassurance about how healthy his heart was to undergo an operation.  An assessment revealed him to be high risk for a coronary event, and I had a lengthy discussion with the surgical team, and the patient, who elected to proceed with the surgery.  Three hours after the surgery, the nurse practitioner taking care of the patient messaged me to tell me his heart rate was slow – ‘in the 30’s’.  I was driving to another hospital, and when stopped, messaged back asking for an electrocardiogram to be sent to me. A quick glance at the image on my screen had me turning around.  There are three major arteries that feed the heart. One of Harry’s arteries had closed off.

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By DAVID INTROCASO

It’s not that we do not know that Medicaid and Medicare fraud is rampant.  A 2012 estimate by the former CMS administrator, Donald Berwick, estimated the amount at $100 billion annually.  Nor are we unaware, that drug companies routinely pay massive fines for illegal business practices: eight firms have paid in sum over $11.2 billion in civil and criminal fines since 2010.  Beyond these issues what is possibly most disturbing about the numerous inter-related health and human services issues “The Poverty Industry” raises is Professor Hatcher’s detailed discussion of how state human service agencies, in partnership with private contractors, have monetized poverty or turned vulnerable populations into a source of state revenue.  As Hatcher says in his introduction, states are, “strip-mining billions in federal aid and other funds from impoverished families, abused and neglected children and the disabled and elderly poor. ” 

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By NIRAN AL-AGBA,MD