A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?
How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.Continue reading…
The New Year always brings many changes. In addition to soon to be broken resolutions, this particular year ushered in strict mandates requiring employers with more than 100 full-time employees to either provide health insurance to those employees or pay fines of between $2000 and $3,000. We’ve seen many firms publicly respond to this by cutting benefits to part-time workers. Despite the criticism that often accompanies these decisions, in many, if not all, of these cases this move benefits employees. Without the offer of employer-provided insurance they get access to the ACA exchanges.
Part of the criticism stems from the implicit belief that firms “give” benefits to their employees out of some form of philanthropy. These benefits are just a tax-preferred (though not really for low-income employees) form of compensation, and research shows that increases in benefit costs result in lower wages for employees. The firms that have cut benefits will either increase wages or lose a lot of employees. (If they cut benefits, do not raise wages, and do not lose workers, then they must not have been profit maximizing to begin with; we highly doubt that firms like WalMart would have knowingly forsaken an opportunity to maximize profits.)Continue reading…
Barring a Republican landslide in 2016, it looks like the Affordable Care Act (ACA) is here to stay. By and large, we think that is a good thing. While there are many things in the ACA that we would like to see changed, the law has provided needed coverage for millions of Americans that found themselves (for a variety of reasons) shut out of the health insurance market.
That being said, since its passage the ACA has evolved and the rule makers in CMS continue to tinker around the edges. We are especially encouraged by CMS’ willingness to relax some of the restrictions on insurance design, but remain concerned about some of the rules governing employers and the definition of what is “insurance.” In the next few blogs we will examine some of the best, and worst, of the ongoing ACA saga.
We start with one of CMS’s best moves—encouraging reference pricing. The term reference pricing was first used in conjunction with European central government pricing of pharmaceuticals. Germany and other countries place drugs into therapeutic categories (such as statins or antipsychotics) and announce a “reference price” which insurers (either public or, in Germany, quasi-public) that insurers will reimburse for the drug. Patients may purchase more expensive drugs, but they were financially responsible for all costs above the references price. Research shows that reference pricing helps reduce drug spending both by encouraging price reductions (towards the reference price) and reducing purchases of higher priced drugs within a reference category. Other research has found suggestive evidence of similar results for reference pricing for medical services.
While the ACA does little to govern pricing in the pharma market, the concept of reference pricing can and should be extended other medical products and services. In particular, insurers can establish reference prices for bundled episodes of illness such as joint replacement surgery. Under the original ACA rules set forth by CMS, insurers were free to establish a fixed price for bundled episodes. They could even require enrollees to pay the full difference between the provider’s price and the reference price. But there was a catch. It wasn’t clear if any spending above the reference price would count to the enrollees by enrollees out of pocket limits (currently $6,600 for individual plans and $13,200 for family plans). Obviously, allowing the out of pocket limit to bind on reference pricing would limit the effectiveness of this cost control measure.
The headlines and their storylines that you’re not likely to read in 2015:
Physicians optimistic about their future. They’re wildly enthusiastic about the mandate to use electronic medical records to coordinate patient care more effectively, and see the shift away from volume to value as positive trend for the industry. Increased penalties about unnecessary care and report cards about their clinical performance are welcomed as physicians embrace transparency. NOT!
Facts: Trust in physicians remains high but has slipped in recent years. Their compensation remains high relative to overall population at 5.8:1, but physician discontent is palpable. And the visibility given their business dealings vis a vis the Physician Sunshine Act and Medicare Physician database is unwelcome and discomforting.
The Affordable Care Act repealed. Overcoming a President veto, the Senate and House approved repeal. The newly insured in Medicaid and health exchanges will be easily absorbed into the current insurance system so the ranks of the uninsured will not swell. NOT!Continue reading…
On the Healthcare.gov web site I was filling the application – an arduous process that – even when pre-filled from last year, takes 30 – 45 minutes. At the review and sign, I found ONE date that was wrong: the day and month were inadvertently transposed. from 09/08 to 08/09. Since the information will be checked against tax records I thought it best to correct this prior to signing.
I clicked on the “edit” button which brought a box “Do you really want to edit your application”, Yes! That’s why I clicked the button – BOOM! back to “GO”,
So it took almost 45 minutes to go through again, (I do work by the way, so this time consuming process is not OK), but I did it. THEN at review I found I had been so frustrated OR the process accepted the key stroke wrong so I now had 09/03 instead of 09/08.
NOT wanting to go back to the very beginning AGAIN, I called the help desk, thinking this would save time. The agent was supportive and pleasant, but basically REFILLED the ENTIRE form again!!!!!!!
JOE wrote THCB with an interesting question that could be an outlier or could be significant:
Do you know of a consulting firm or advisory firm that can assist me in applying for insurance through Covered California? When I applied for insurance through the Covered California website, they gave me a list of places where I can get assistance. The phone numbers go to dead voice mail boxes or don’t work at all. I am willing to pay for assistance from somebody that understands the system.
In the giddy days after the passage of ACA, I was chatting to a PhD student in health economics. He was in love with the ACA. He kept repeating that it would reduce costs, increase quality and increase access. Nothing original. You know the sort of stuff you heard at keynotes of medical meetings; ‘Healthcare post Obamacare’ or ‘Radiology in the new era.’ Talks warning us that we were exiting the Cretaceous period.
He spoke about variation in healthcare, six sigma, fee-for-value and ‘paying doctors to do the right thing.’
‘How?’ I asked.
‘I just told you, we need to pay doctors for value and outcomes.’ He smugly replied.
‘How?’ I asked again.
He did not answer. Instead he gave me the look that one gives an utter imbecile who doesn’t know the difference between a polygon and a triangle.Continue reading…
Making Sense of Blue Button, Meaningful Use, and What’s Going on in Washington …
At the recent Health 2.0 Conference in Santa Clara, co-chair Matt Holt expressed frustration about the difficulty of getting copies of his young daughter’s medical records. His experience catalyzed a heated discussion about individuals’ electronic access to their own health information. Many people are confused about or unaware of their legal rights, the policies that support those rights, and the potential implications of digital access to health data by individuals. The Health 2.0 conference crowd included 2000 entrepreneurs, consumer technology companies, patient advocates, and other potentially “disruptive” forces in healthcare, in addition to more traditional health system players.
Why is this topic so important? Until now, most people haven’t accessed their own health records, whether electronically or in paper, and I believe that making it easier to do so will help tip the scales toward more meaningful consumer/patient engagement in healthcare and in health. Access by individuals and their families to their own health records can empower them to coordinate care among multiple healthcare providers, find and address dangerous factual errors, and take advantage of a growing ecosystem of apps and tools for improving health-related behaviors, saving money on health services, and getting more convenient, personalized care.
A shorthand phrase for this kind of personal empowerment through access to digital health data is “Blue Button,” which is also the name of a public-private initiative in which hundreds of leading healthcare organizations across the US participate. The Blue Button Initiative is bolstered by the electronic access to health information requirements for patients in the “Meaningful Use” EHR Incentive Program, which is administered by CMS (the Centers for Medicare & Medicaid Services) with companion standards and certification requirements set by ONC (the Office of the National Coordinator for Health Information Technology).Continue reading…
Last Tuesday at midnight, CVS officially changed its name to CVS Health and simultaneously cleared its 7,700 retail stores of tobacco products a month earlier than previously reported. Its stores will be called CVS Pharmacy with plans to expand its 900 primary care clinics to 1,500 by 2017, and its $90 billion pharmacy benefits management unit, CVS Caremark, continuing to play a key role in serving its 65 million customers(1).
And the following day, the CMS Office of the Actuary released its forecast of health spending, predicting that health spending will likely return to 6% annual increases for the next decade(2).
No doubt, the timing of the two is coincidental. But taken together, they paint a future state in healthcare that’s distinctly different from its recent past.
While fierce debate continues to envelop much of the Affordable Care Act, financial data for many of the nation’s health systems reveal one clear fact: the optional Medicaid expansion has resulted in hospital haves and have nots.
An analysis by PwC’s Health Research Institute (HRI) of newly released earnings and patient volume data shows a clear financial split between healthcare providers operating in states that expanded Medicaid and those that have not. The law as written would have provided Medicaid coverage to every American earning less than 138% of the federal poverty level ($16,105 for an individual). But a June 2012 Supreme Court ruling made the expansion optional for states, creating a patchwork of coverage.
Health systems and physician groups delivering care in the 26 states and the District of Columbia that have embraced the federally-funded expansion have reported a significant rise in patient volumes and paying consumers and a measureable reduction in uncompensated care levels.
This year alone LifePoint Hospitals has seen a 30.3% reduction in its uninsured and charity care patients, according to filings with the Securities and Exchange Commission. Tenet Healthcare, which operates in five Medicaid expansion states, saw uninsured and charity care admissions decline by 46% in the expansion states, coupled with a 20.5% increase in Medicaid inpatient admissions in those same states, according to an HRI analysis which will be released next week.
In all, HRI analyzed financial data from the nation’s five largest for-profit health systems—HCA Holdings, LifePoint, Tenet, Community Health Systems and Universal Health Services, representing 538 hospitals in 35 states. Our team also reviewed data from several mid-sized hospitals, government reportsand industry surveys.