Tag: Health policy

The Reality of Bush I on Health Care and Its Lessons for Today

Dec 3, 2018• 2

By MICHAEL L. MILLENSON

Former President George H.W. Bush may have been every inch the caring individual portrayed in the eulogies of those who knew him, but when it came to health care reform, two words characterized his attitude: Don’t care.

However, compared to Congressional Republicans, Bush was a profile in conservative courage – a lesson with unfortunate parallels to now.

I covered health policy as a reporter for the Chicago Tribune during the Bush years. One strong memory, confirmed by checking original sources, was the presidential debate on Sept. 25, 1988 between Bush and his Democratic challenger, Massachusetts Gov. Michael Dukakis. When Bush was asked what he’d do for the 37 million people without health insurance – about one in seven Americans – he answered that he would “permit people to buy into Medicaid.”

I remember turning from the TV to my wife and saying, “I have no idea what he’s talking about.” Neither, apparently, did anyone else. A Washington Post story that followed, headlined, “Bush’s Mysterious Medicaid Plan” noted that seeking details from the Bush campaign yielded “answers [that] are contradictory.” The story added that “Bush had never publicly mentioned the idea” until the debate.

The MSSP Is No Silver Bullet for Healthcare Cost Control

Nov 19, 2018• 16

But ACOs could pave the way for more significant cost-cutting based on competition.

By KEN TERRY

The Medicare Shared Savings Program (MSSP), it was revealed recently, achieved a net savings of $314 million in 2017. Although laudable, this victory represents a rounding error on what Medicare spent in 2017 and is far less than the growth in Medicare spending for that year. It also follows two years of net losses for the MSSP, so it’s clearly way too soon for anyone to claim that the program is a success.

The same is true of accountable care organizations (ACOs). About a third of the 472 ACOs in the MSSP received a total of $780 million in shared savings from the Centers for Medicare and Medicaid Services (CMS) in 2017 out of the program’s gross savings of nearly $1.1 billion. The other MSSP ACOs received nothing, either because they didn’t save money or because their savings were insufficient to qualify them for bonuses. It is not known how many of the 838 ACOs that contracted with CMS and/or commercial insurers in 2016 cut health spending or by how much. What is known is that organizations that take financial risk have a greater incentive to cut costs than those that don’t. Less than one in five MSSP participants are doing so today, but half of all ACOs have at least one contract that includes downside risk.

As ACOS gain more experience and expand into financial risk, it is possible they will have a bigger impact. In fact, the ACOs that received MSSP bonuses in 2017 tended to be those that had participated in the program longer—an indication that experience does make a difference.

However, ACOs on their own will never be the silver bullet that finally kills out-of-control health spending. To begin with, 58 percent of ACOs are led by or include hospitals, which have no real incentive to cut payers’ costs. Even if some hospitals receive a share of savings from the MSSP and/or private insurers, that’s still a drop in the bucket compared to the amount of revenue they can generate by filling beds instead of emptying them. So it’s not surprising that physician-led ACOs are usually more profitable than those helmed by hospitals.

Mrs. Verma Goes to Washington

Nov 15, 2018• 13

By ANISH KOKA MD

Seema Verma, the Trump appointee who runs Medicare, has had an active week. The problem facing much-beloved Medicare is one that faces every other government-funded healthcare extravaganza: it’s always projected to be running out of money. Medicare makes up 15% of the total federal budget. That’s almost $600 billion dollars out of a total federal outlay of $4 Trillion dollars. The only problem here is that revenues are around $3.6 trillion. We are spending money we don’t have, and thus there there is constant pressure to reduce federal outlays.

This is a feat that appears to be legislatively impossible. The country barely is able to defund bridges to nowhere let alone try to reduce health care spending because, as everyone knows, any reduction in health care spending will spawn a death toll that would shame the black plague. The prior administration’s health policy wonk certified approach was to change the equation in health care from paying for volume to paying for value. This, we were assured, would allow us to get better healthcare for cheaper! And so we got MACRA, The Medicare Access and CHIP Reauthorization Act, that introduced penalties for doctors unable to provide ‘good’ care. Never mind that in some years good care means you treat everyone with a statin, and in others it means treat no one with a statin. When in Rome, live like the Romans. In 2018 parlance, that roughly translates to “check every box you can and everything will be all right.”Continue reading…

All Health Policy Is Local: The Case of the Individual Mandate Penalty in New York

Oct 29, 2018• 2

By CHRISTINE EIBNER PhD, SARAH NOWAK PhD, MS, PREETHI RAO PhD

Although signed into law in 2010, the Affordable Care Act has been in constant flux, with key aspects changing due to time-dependent provisions, Supreme Court decisions and shifts in U.S. policy. The effects of changes to the ACA on health insurance enrollment and premiums often depend on state regulatory decisions and other state-specific factors. The elimination of the individual mandate penalty is a prime example of this when applied to New York state, which has unusual rules in its individual insurance market.

In 2019, consumers will no longer face financial penalties stemming from the ACA’s individual mandate, which requires most people to secure health insurance. Without pressure from the individual mandate to enroll, younger and healthier people might drop coverage, leading to premium increases. New York’s health insurance regulations and expansive safety-net programs could make the state’s insurance market particularly susceptible to premium increases after the penalty’s elimination.

New York uses what is known as “full community rating” in its individual health insurance market, which means that all adult enrollees, regardless of age or whether they use tobacco, are charged the same premium. In most states, the youngest adults in the market pay one-third of what older adults do, and tobacco users are charged 1.5 times as much as non-users. New York’s flat premium structure raises costs for younger enrollees and nonsmokers, making them more likely drop coverage when the penalty goes away.

A conversation about Health Policy with Elizabeth Rosenthal

Oct 22, 2018• 7

By SAURABH JHA, MD

The acclaimed author of “An American Sickness: How Healthcare Became Big Business and How You Can Take It Back” physician, and now Editor-in-Chief of Kaiser Health News, Dr. Elizabeth Rosenthal speaks to me about health policy and how it has changed over time.

Listen to our conversation at Radiology Firing Line Podcast.

About the author:

Saurabh Jha is a contributing editor to THCB and host of Radiology Firing Line Podcast of the Journal of American College of Radiology, sponsored by Healthcare Administrative Partner

The C Word

Apr 11, 2016• 29

By JEFF GOLDSMITH

flying cadeucii That we are experiencing a “consumer revolution” in healthcare is a durable meme in the media and in policy circles just now. When you hear the word “consumer”, it conjures images of someone with a cart and a credit card happily weaving their way through Best Buy. It is, however, a less than useful way of thinking about the patient’s experience in the health system.

A persistent critique of our country’s high cost health system is that because patients are insulated from the cost of care by health insurance, they freely “consume” it without regard to its value, and are absolved of the need to manage their own health. In effect, this view ascribes our very high health costs to moral failure on the part of patients.

Market-oriented policy advocates believe that if we “empower”patients as consumers by asking them to pay more of the bill, market forces will help us tame the ever rising cost of care. If patients have “skin in the game” when they use the health system and also “transparency” of health providers’ prices and performance, patients can deploy their own dollars more sensibly.

This concept played a major role in the otherwise “progressive” Affordable Care Act. The 13 million people who signed up for coverage this year through the Affordable Care Act’s Health Exchanges opted overwhelmingly for subsidized policies with very high deductibles and out-of-pocket cost limits. The “skin in the game” argument has also heavily influenced corporate health benefits decisions. More than 30 million workers and their families receive high deductible plans through employers.

The Anti-Hypocrisy Rule

Dec 10, 2014• 24

By MARTIN SAMUELS, MD

Pundits abound when it comes to health care plans. They come from many different backgrounds: conservatives, liberals, academics, business people, doctors, politicians and more often all the time various combinations of these. But they all have one characteristic in common. They all want a different kind of health care for themselves and their families than they profess for everyone else.

I am acutely aware of this as I am in a position that demands that I find special appointments for them. A day virtually never passes when I don’t receive requests (often many in a single day) for me to either see these people myself or arrange for their special care elsewhere, including other parts of the county and the world. My own personal ethical code of conduct prevents me from mentioning their names or anything that could identify them. Suffice it to say that I have yet to see a single exception to this principle.

Mission Critical: How Translation-Focused Disease Foundations May Save Medical Research

Apr 23, 2012• 1

By David Shaywitz, MD

Patients waiting expectantly for medical research to produce important new cures are finding bad news almost everywhere they turn.

Pharmaceutical companies are suffering from a much-discussed innovation crisis, as old drugs lose patent protection without new drugs to replace them; meanwhile, the small biotechs that could potentially bail big pharma out struggle to raise capital .

University scientists, for their part, are beset by an unseemly credibility crisis, as the intrinsic fragility of medical research is now vividly apparent from the soaring number of high-profile retractions, and the well-documented difficulty of reproducing many published findings outside the originator’s lab.

At the heart of this crisis is the misalignment of two very different cultures.

Academic scientists tend to focus on publishing papers, and usually assume that the results will eventually be useful. They place a high value on novelty, and relatively less value on whether the data are robust, easily reproducible by others, or truly relevant to human disease. Captivating data from putative laboratory models of disease generate publications, even if the model is not very predictive of human disease – and unfortunately, most models aren’t.

Conversely, big companies traditionally focus on generating efficiencies through scale, and on developing reproducible processes. This works very well for manufacturing, reasonably well for large late-stage clinical trials, and essentially not at all for early-stage (discovery) research.

What Does Failure Mean?

Jan 23, 2012• 2

By Aaron Carroll, MD

I’ve seen a number of responses to the news that the Medicare demonstration projects were not successful. Some have claimed that they were only demonstration projects, and the fact that some succeeded means we should look into those further. Others asserted that this once again proves that the government is incapable of making the health care system better.

As to the first point, it’s hard to get excited about this. By chance alone, a couple of programs were likely to save money. Four out of 34 reducing hospitalizations (when the best of them might have had inadequate data)? Hardly something to get excited about. Remember that two out of the 34 actually saw increased hospitalizations, too. I think it’s totally reasonable to think hard before just assuming there was something special about those four programs, and throwing more money at them.

But I think the latter point, made by Peter Suderman, is a bit of an over-reach as well. It’s important to remember that these were attempts by private hospitals and private physicians to change the way they care for patients. Granted, government was paying the insurance bills through Medicare, but this would have looked awfully similar if a private company had footed the bill. And, yes, private insurance companies have tried to use care coordination and disease management to reduce costs as well.

A Win-Win: Job Creation Will Grow the Economy and Improve Health

Jan 16, 2012• 7

By Risa Lavizzo-Mourey, M.D. and Mark Pinsky

The current economic recovery effort presents an opportunity to build stronger, healthier communities. That’s a central goal for the Create Jobs for USA Fund that Opportunity Finance Network (OFN) and Starbucks launched late last year to support job creation and retention.

Economic growth and job creation provide more than income and the ability to afford health insurance and medical care. They also enable us to live in safer homes and neighborhoods, buy healthier food, have more leisure time for physical activity, and experience less health-harming stress. The research clearly shows that health starts in our homes and communities and not in the doctor’s office.

In that way, economic policy is, in fact, health policy.

Since 1985, OFN’s national network of community development financial institutions (CDFIs) has loaned more than $23 billion to benefit low-income, low-wealth, and other disadvantaged communities. The Robert Wood Johnson Foundation (RWJF), with an endowment of around $8.5 billion, is the nation’s largest philanthropy focused solely on improving health and health care for all Americans. Marrying the business acumen of CDFIs and others to health philanthropy’s ability to supply the research, analysis, and expertise to make sure community development activities improve residents’ health is a powerful union.