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The Oregon Experiment Revisited

It has been a couple of weeks since the landmark Oregon Experiment paper came out, and the buzz around it has subsided.  So what now?  First, with passage of time, I think it is worth reflecting on what worked in Oregon.  Second, we should take a step back, and recognize that what Oregon really exposed is that health insurance is a small part of a much bigger story about health in general.  This bigger story is one we can’t continue to ignore.

So let’s talk quickly about what worked in Oregon.  Health insurance, when properly framed as insurance (i.e. protection against high, unpredictable costs) works because it protects people from financial catastrophe.  The notion that Americans go bankrupt because they get cancer is awful and inexcusable, and it should not happen. We are a better, more generous country than that.  We should ensure that everyone has access to insurance that protects against financial catastrophe.  Whether we want the government (i.e. Medicaid, Medicare) or private companies to administer that insurance is a debate worth having.  Insurance works for cars and homes, and the Oregon experiment makes it clear that insurance works in healthcare.  No surprise.

The far more interesting lesson from Oregon is that we should not oversell the value of health insurance to improving people’s health.  While health insurance improves access to healthcare services (modestly), its impact on health is surprisingly and disappointingly small.  There are two reasons why this is the case.  The first is that not having insurance doesn’t actually mean not having any access to healthcare.  We care for the uninsured and provide people life-saving treatments when they need it, irrespective of their ability to pay.  Sure – we then stick them with crazy bills and bankrupt them – but we generally do enough to help them stay alive.  Yes, there’s plenty of evidence that the uninsured forego needed healthcare services and the consequences of being uninsured are not just financial.  They have health consequences as well.  But, claims like 50,000 Americans die each year because of a lack of health insurance? The data from Oregon should make us a little more skeptical about claims like that.

So what really matters?  Right now, we are pouring $2.8 trillion into healthcare services while failing to deliver the basics.  To borrow a well-known phrase, our healthcare system is perfectly designed to produce the outcomes we get – and here’s what we get: mediocre care and lousy outcomes at high prices.  Great.

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Think NCAA Athletes Shouldn’t be Paid? What the Kevin Ware Story Says About the Risks of College Sports


In many ways, it had been an exemplary few days for the NCAA and its signature basketball tournament—a weekend that put the madness back in March.

On Friday, Michigan and star guard Trey Burke completed an epic comeback over Kansas. On Saturday, Cinderella team Wichita State crashed the Final Four.

But for many people watching the Louisville-Duke game unfold, a disturbing injury to Louisville guard Kevin Ware illustrated a different sort of madness: the continued lack of compensation for the players who make the tournament so special.

“Pray for [Ware],” columnist Dave Zirin tweeted. “There is no safety-net for the injured NCAA athlete.”

Injury worst seen on TV

Ware’s broken leg—”about the most gruesome injury I’ve seen in a basketball game,” bemoaned analyst Seth Davis—came on a routine play, as he landed awkwardly after trying to block a shot by Duke’s Tyler Thornton.

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Why Only Business Can Save America From Health Care

For a large and growing number of us with meager or no coverage, health care is the ultimate “gotcha.” Events conspire, we receive care and then are on the hook for a car- or house-sized bill. There are few alternatives except going without or going broke.

Steven Brill’s recent Time cover story clearly detailed the predatory health care pricing that has been ruinous for many rank-and-file Americans. In Brill’s report, a key mechanism, the hospital chargemaster, with pricing “devoid of any calculation related to cost,” facilitated US health care’s rise to become the nation’s largest and wealthiest industry. His recommendations, like Medicare for all with price controls, seem sensible and compelling.But efforts to implement Brill’s ideas, on their own, would likely fail, just as many others have, because he does not fully acknowledge the deeper roots of health care’s power.

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Can Health Care Transparency Make A Difference?

There’s been a lot of discussion of transparency in health care recently, e.g., a USA Today op-ed and a counterpoint by Paul Ginsburg. The appeal of transparency is obvious. As movingly documented by Steven Brill in Time, prices are high and often differ quite substantially, even across close by providers. However, we don’t know the prices for the health care that we consume, and it’s extremely difficult to find out what these things cost (e.g., this recent study in JAMA).

While the appeal of transparency is obvious, it’s important to realize that buying health care is not like buying milk at the grocery store. A key factor is health insurance. Health insurance is very important — people need to be insured against the catastrophic expenses that can occur with serious illness. Thus people with high health care expenses won’t be exposed to most of those expenses (and shouldn’t) and therefore will have no reason to respond to information about health care prices.

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Rob’s New Economics of Practice Management

It has always been my assumption that my new practice will be as “digital” as possible. No, I am not going into urology, I am talking about computers. [Waiting for the chuckles to subside]

For at least ten years, I’ve used a digital EKG and spirometer that integrated with our medical record system, taking the data and storing it as meaningful numbers, not just pictures of squiggly lines (which is how EKG’s and spirometry reports appear to most folks). Since this has been obvious from the early EMR days, the interfaces between medical devices and EMR systems has been a given. I never considered any other way of doing these studies, and never considered using them without a robust interface.

Imagine my surprise when I was informed that my EMR manufacturer would charge me $750 to allow it’s system to interface with a device from their list of “approved devices.” Now, they do “discount” the second interface to $500, and then take a measly $250 for each additional device I want to integrate, so I guess I shouldn’t complain. Yet I couldn’t walk away from this news without feeling like I had been gouged.

Gouging is the practice of charging extra for someone for something they have no choice but to get. I need a lab interface, and the EMR vendor (not just mine, all of the major EMR vendors do it) charges an interface fee to the lab company, despite the fact that the interface has been done thousands of times and undoubtedly has a very well-worn implementation path. This one doesn’t hurt me personally, as it is the lab company (that faceless corporate entity) that must dole out the cash to a third-party to do business with me.

Doing construction in my office, I constantly worry about being gouged. When the original estimate of the cost of construction is again superseded because of an unforeseen problem with the ductwork, I am at the mercy of the builder. Fortunately, I think I found a construction company with integrity. Perhaps I am too ignorant to know I am being overcharged, but I would rather assume better of my builders (who I’ve grown to like).

Yet thinking about gouging ultimately brings me back to the whole purpose of what I am doing with my new practice, and what drove me away from the health care system everyone is so fond of. If there is anywhere in life where people get gouged or are in constant fear of gouging, it is in health care. Continue reading…

Health Care Purchasers, Consumers Need Price Data if We Are Ever Going to Get to a System of Value-Based Care

In a world where health care costs are rising and consumers are taking on a growing share, it is critical they have easy access to understandable information about the quality and cost of their care.  While we have made decent strides in making quality data available, consumers still have little to no information about health care prices, making it difficult if not impossible for them to seek higher-value care.  Numerous studies and articles have explored this problem, such as a recent UCSF study, highlighted in JAMA, which found routine appendectomies can cost as little as $1,529 or as much as $183,000.  As PBGH Medical Director Dr. Arnie Milstein so eloquently stated in the Wall Street Journal, “Fantasy baseball managers have more information evaluating players for their teams than patients and referring physicians have in matters of life and death.”

Now Catalyst for Payment Reform (CPR), an independent, non-profit corporation working on behalf of large employers and other health care purchasers to catalyze improvements in how we pay for health services, has just released a suite of tools to catalyze price transparency.  The suite includes a first-of-its-kind Statement by CPR Purchasers on Quality and Price Transparency in Health Care, endorsed by several partner organizations, that takes plans and providers to task: give us price data by January 2014.

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Hospitals…Thinking About Getting Into Health Insurance? 6 Reasons To Lie Down Until the Urge Goes Away.

Gregg Masters reports on a recent Kaiser Health News article: Hospitals Look to Become Insurers, As Well as Providers of Care”.

This is the dumbest idea I’ve heard since “I’m going to invest all my money in Facebook’s IPO and get rich!”

Here are six reasons why:

1) You’re too late. Health insurance was an attractive and profitable business in the 00s, but after passage of the Accountable Care Act it’s been commoditized.

First, the health plan business model of the past decade is dead. That model was — “Avoid and shed risk” — or more simply, avoid insuring people who are already sick (preexisting conditions) and get rid of people who become sick (rescissions). Under the ACA, health insurers must take all comers and they can rescind policies only for fraud or intentional misrepresentation.

Second, the ACA institutes medical loss ratio restrictions on health insurers. Depending the the type of plan, insurers now must spend at least 80-85% of premium dollars on paying medical claims; if they spend less, they must return these “excess profits” as rebates to customers. As a result, health insurance has become a highly regulated quasi public utility.

This is why you see health plan CEOs like Mark Bertolini of Aetna declaring “Health insurers face extinction”. The old health insurance model is on a burning platform, and health plans are reformulating themselves as companies involved in health IT, analytics, data mining, etc.

2) You have bigger fish to fry. Focus on developing accountable care capabilities. The AHA estimated that hospitals will need to spend $11-25 million to develop an ACO. Get going.
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Health Care Power Tools for Consumers

Most people are getting their health insurance through their employer. That has been changing slowly, but with healthcare reform, many more people will be left to select their own plans without the pre-selection and help from their employer. What used to be a choice among 3-5 plans is soon to become a selection from dozens of health insurance companies each offering a dozen plans to choose from. And selecting an insurance plan is not like getting car insurance; family makeup, prior health issues, future healthcare needs, and affordability – they all matter. In other words, it’s very personal.

As in other insurance industries, there will be a number of options to help consumers, such as agents and brokers. Cost is one of the most important criteria, but the problem of predicting the impact of plan choices on out-of-pocket costs is much harder, since selecting a plan is such a personal choice. Our needs and therefore expenses also change over time, as we go through different life stages.

As in many industries, there is a lot of data one can harness to help with these decisions. One benefit we see emerging is the availability of personal power tools (similar to financial planning tools) that allow for detailed modeling of an individual or family’s situation. These tools predict likely health care needs and allow one to compare the detailed expenses given different insurance plans. Starting a family? Entering your fifties, with its slew of clinically advised exams? Dealing with the ups and downs of a chronic condition? Those factors can all be taken into account to provide detailed plan options and price comparisons to help choose the optimal health plan.

 

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Commerce Clause Challenges to Health Care Reform

The following article, forthcoming in U. Penn. L. Rev., pinpoints the strongest arguments for and against federal power under the Commerce Clause to mandate the purchase of health insurance:   http://papers.ssrn.com/sol3/papers.cfm?abstract_id=1747189

Among the key points I make in defense of this federal law are:

1. The “commerce” in question is simply health insurance, and not the non-purchase of insurance as challengers have framed it.  Because “regulate” clearly allows both prohibitions and mandates of behavior, mandating purchase is lexically just as valid an application of the clause as is prohibiting purchase or mandating the sale of insurance.

2. Although existing precedent might allow a line to be drawn between economic activity and inactivity, there is no reason in principle or theory why such a line should be drawn in order to preserve state sovereignty.  Purchase mandates, after all, are as rare under state law as under federal law.

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OIG: Imaging pre-authorization may be handled by hospital for referring docs and patients

The OIG released an advisory opinion at the end of last month OK’ing a hospital’s proposal to provide insurance pre-authorization srevices free of charge to patients and physicians. This is an issue that has long vexed folks in the imaging world. Clearly, this is a free service provided to referral sources (to the extent they are obligated by contract with third party payors to obtain the pre-authorization before referring a patient for an MRI, for example), so why is the OIG OK with it?  In the opinion, the OIG blesses the arrangement for four reasons:

  • The arrangement doesn’t target specific referring docs, so the pre-authorization service will be provided for patients of docs who are contractually bound to handle it themselves, as well as for patients of those who aren’t, and thus the risk of using the arrangement to reward referrals is low
  • The hospital will not pay the docs under the arrangement and will not guarantee to docs that the pre-authorizations will be forthcoming (the OIG also notes — not sure why — that the hospital will collect and pass on only such personal health information as may be necessary to secure a finding of medical necessity for the pre-authorization)
  • The hospital staff will be transparent with payors and referring docs, and will have little influence on steering volume, because they get involved only after the hospital has been selected (other situations are distinguished, e.g., where referral seekers provide referral sources with staff like discharge planners)
  • The hospital has an interest in being paid for its services, and thus in ensuring that the pre-authorization process is conducted properly, thus “lower[ing] the risk that the … [a]rrangement is a stalking horse for illicit payments to [the hospital’s] referral sources”

Well, the reasoning here doesn’t really cut it, as far as I’m concerned. Referring docs and their staffs hate having to deal with the pre-authorization process, and if a hospital takes on that headache, that’s a real benefit (remuneration, in the language of the anti-kickback statute). If there are two hospitals in town, and — all other things being equal — one provides pre-authorization services and the other doesn’t, guess where all the docs will refer their patients? It doesn’t really matter that the service is provided to all docs, for all payors. It is still clearly an inducement. If, on the other hand, all hospitals take on this added cost of doing business, then nobody gains a competitive advantage. Finally, to the e xtent physician networks are more and more tightly tied to particular hospital systems (whether through employment or other relationships, post health reform), the potential for steering volume is negligible at best.

Bottom line: I agree with the outcome, but not the reasoning.

David Harlow writes at HealthBlawg:David Harlow’s Health Care Law Blog, a nationally-recognized health care law and policy blog. He is an attorney and lectures extensively on health law topics to attorneys and to health care providers. Prior to entering private practice, he served as Deputy General Counsel of the Massachusetts Department of Public Health.

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