The Health Care Blog – Page 505 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

The ACA: When Insurance Isn’t Insurance

Jan 21, 2014• 72

By David Dranove & Craig Garthwaite

We will be blunt. Hidden under the cloak of expanding health insurance, the Affordable Care Act (ACA) has fostered a massive subsidization of healthcare goods and services.

These subsidies often have little or anything to do with what economists would consider the “insurance” part of health insurance – providing protection against financial catastrophe.

Perhaps more troubling, if the past is prologue these subsidies will continue to grow, transferring huge amounts of money to politically favored groups and doing very little to decrease aggregate health spending – a presumed goal of health reform.

In order to understand these claims, it is necessary to take a step back and explain why insurance (of any form) is a good thing in the first place. Simply stated, insurance provides individuals with protection against unpredictable financial hardships not of their own making.

Most of us don’t like risk, and therefore we are willing to pay other people to avoid uncertain outcomes. Therefore the benefits of insurance are to protect us from uncertain events.

The key here is the uncertainty. If something is not going to cause financial distress, or the expense is relatively predictable, then, by definition, the service is not insurable. A health plan could cover the service, but that is a subsidy, i.e. other people in the insurance pool or an outside actor such as the government are simply paying for your service. It is not insurance.

Sadly, most of the discussion around what constitutes “real” health insurance under the ACA bears only a passing resemblance to the protection against financial risk that is the hallmark of insurance. For example, Secretary of Health and Human Services Kathleen Sebelius said: “Some of these folks have very high catastrophic plans that don’t pay for anything unless you get hit by a bus … They’re really mortgage protection, not health insurance.”

What does Secretary Sebelius think insurance is? We don’t expect auto insurance to pay for our gasoline.

Field Report from JP Morgan 2014

Jan 21, 2014

By Paul Keckley

Last week, HHS issued its much-anticipated report about the first wave of enrollees in the state and federal health exchanges. Its release coincided with the 32nd Annual J P Morgan Healthcare Conference in San Francisco, arguably Woodstock for health care investors.

HHS reported that, as of December 28, 2.2 million signed up for coverage. They are older and probably sicker than the overall population of 50 million uninsured in the U.S.:

Per the analysis, 54% of these are female, 71% are eligible for financial assistance and most signed up for silver plans (60%) vs. the more expensive platinum (7%) and gold (13%) or the less costly bronze (1%) options.

The 14 states run exchanges fared well in the first 90 days accounting for 956,991 enrollees—most in blue states where governors were supportive of the exchange effort. In fact, 10 exceeded their enrollment target even though the national target fell 1.1 million short.

Why Maintenance of Certification Will Make You a Better Doctor

Jan 20, 2014• 73

By Lois Margaret Nora, MD

Whether having meals with physician-relatives, attending a professional society meeting, or walking the halls of a hospital, I find that a common issue on physicians’ minds during our discussions is the American Board of Medical Specialties’ (ABMS) Board Certification process – and particularly our program for maintaining certification known as Maintenance of Certification (MOC).

Questions range from “I know you’re old enough to have grandmother status – do YOU do MOC?” (Yes) to “How can I fit this into my already insanely busy life?” Comments range from appreciation for some aspect of the program to frustration with one of the program components.

As the relatively new leader of ABMS, I welcome the opportunity to discuss issues pertaining to Board Certification and MOC. I hope this post will generate thoughtful dialogue that will result in continuing improvements to the certification process developed by ABMS and our 24 Member Boards. That, in turn, will help us render MOC more relevant and meaningful to participating physicians and will assist them in their efforts to provide quality patient care and improve our health care system.

For many years there were few, if any, requirements for maintaining ABMS Board Certification. Physicians took an exam after graduating from their residencies and thereafter had no further obligations for testing or evaluation. However, over time the error of this approach became obvious. Medical science continuously changes, and the pace of that change has accelerated.

The Great ACO Debate: 2014 Edition

Jan 19, 2014• 12

By Joseph Damore & Wes Champion

With the beginning of 2014 comes another year of the great accountable care organization (ACO) debate.

Is it a model to deliver high-quality, cost-effective care and improve population health management (PHM)? Or, just a passing fad, similar to the HMOs of decades ago?

Many opinions exist, and they’ll continue to be debated, especially during an election year. One thing most of us can agree on about ACOs is they are a work in progress.

We can say with some certainty that ACOs are taking hold; look no further than their growth, which now exceeds 600 public and private ACOs nationwide with the recent addition of 123 ACOs to the Medicare Shared Savings Program. But they still beg more questions than answers. What types and sizes of hospitals are forming ACOs, and where are they located? What does the pipeline of emerging ACOs look like, and how long will their journey take? And what capabilities, investments and partnerships are essential to ACO participation? What is the longer term performance?

Who better to ask than the decision makers running the organizations that participate in an ACO?

In August of 2013 we surveyed 115 C-suite executives– primarily CEOs (43.5%), chief financial officers (17.4%) and chief operating officers (16.5%) – across 35 states to collect data on their perspectives on ACO and PHM.

Survey results support the increase in ACO popularity. According to respondents, ACO participation has almost quadrupled since spring 2012: More than 18% say their hospitals currently participate in an ACO, up from 4.8% in spring 2012. This growth is projected to accelerate, with about 50% of respondents suggesting their hospitals will participate in an ACO by the end of 2014. Overall, 3 out of 4 senior executives surveyed say their hospitals have ACO participation plans.

Since survey respondents also represent hospitals of different locations, sizes and types, we are able to obtain a broader look at current and future ACO participation and found that:

Non-rural hospitals (82.1%) are most likely to participate in an ACO overall, followed by hospitals in an integrated delivery network (81.1%).
The lowest rates of projected participation are among rural hospitals (70.7%) and standalone hospitals (72.6%).
Large hospitals are moving more quickly, as 30.8% said they’d be part of an ACO by the end of 2013.
And though they’re equally as likely as large hospitals to ultimately participate in an ACO, small hospitals say they require additional time, with 48.6% planning to join in 2014 or 2015.

But some providers have been more deliberate and cautious about when they start their ACO journey. The pace of ACO adoption has been slower than originally anticipated 18 months ago, when more than half of executives predicted their systems would create or join an ACO by the end of 2013. Current survey results show that about 1 out of 4 will meet that projection.

Another Metric for Tracking Plan Successes

Jan 19, 2014• 2

By Jaan Sidorov, MD

Quick: If you had to chose a limited number of measures to gauge success of the Affordable Care Act, what would you choose? Would it be the number of persons who have enrolled in healthcare.gov?

The number of persons who have paid for their insurance and have coverage? The number of young people with coverage? The degree of spin used by the White House?

The U.S. House of Representatives thinks it’s an important topic. They just passed legislation requiring weekly updates on the operation of healthcare.gov.

But here is one proposed measure that can help cut through the maze of competing claims and partisan spin:

The percent of persons with either 1) “silver” or 2) “bronze” plans who have gone two or more months without paying their insurance premium.

Why, you ask? The silver and bronze plans, because their monthly premium is lower, will attract a disproportionate number of persons who were previously unable to afford health insurance and are now newly insured.

According to this just published JAMA article, even if their monthly premiums are fully or partially subsidized, these lower-cost insurance plans cover only up to 60% to 70% of medical expenses.That means cost sharing that can be excess of $6000 and $12,000 for individuals and families, respectively.

The Uninsured Are Not Signing Up for Obamacare

Jan 19, 2014• 8

By Robert Laszewski

In my last post, I asked, “But what if most of the uninsured literally don’t buy Obamacare?”

“Only 11% of consumers who bought new coverage under the law were previously uninsured,” according to a survey of 4,563 consumers eligible for the health insurance exchanges done by McKinsey & Company and reported in Saturday’s Wall Street Journal.

The Journal reports that “insurers, brokers, and consultants estimate at least two-thirds” of the 2.2 million people who have so far signed up in the new exchanges are coming from those who already had coverage.

This is consistent with anecdotal reports from insurers I have talked to that are seeing very little net growth in their overall individual and small group markets as of January 1.

That’s even worse than I thought it would be even considering the January 1 individual policy cancellations and small group renewals that are driving employers to reconsider offering coverage––and that is saying something. The vast majority of the individual cancellations, particularly because of the early renewal and extension programs, are yet to come. The same can be said for the small group renewals.

This also tells us why the first three months of the Obamacare enrollment had a relatively high average age––they came from the same market that tended to skew older that the health plans already covered.

When McKinsey asked why subsidy eligible people weren’t buying, 52% cited affordability as the reason. Readers of this blog will know that I’m not shocked to hear that given what I have been writing about the high after-tax premiums, net of the subsidies, people are finding, as well as the high deductibles and narrow provider networks the subsidized Silver and lowest cost Bronze exchange plans are offering people.

Another 30% cited “technical challenges” with the website as reasons they have not yet bought. That said, enrollment in the state exchanges that have generally been running well––California, Washington state, New York, Connecticut, Kentucky, and Colorado are also only enrolling a very small number of people relative to the number of policy cancellations in their markets and the size of their uninsured population.

Private exchange Health Markets reports that of the 7,500 people it has enrolled, 65% had prior coverage.

Survey Says: EHR Incentive Program Is on Track

Jan 17, 2014• 98

By Karen DeSalvo, MD

We continue to see progress in improving the nation’s health care system, and a key tool to helping achieve that goal is the increased use of electronic health records by the nation’s doctors, hospitals, and other health care providers. These electronic tools serve as the infrastructure to implementing reforms that improve care – many of which are part of the Affordable Care Act.

Doctors and hospitals are using these tools to reduce mistakes and hospital readmissions, provide patients with more information that enable them to stay healthy, and allow for rewarding health care providers for delivering quality, not quantity, of care.

The adoption of those tools is reflected today in a release from the Centers for Disease Control and Prevention’s National Center for Health Statistics which provides a view of the Medicare and Medicaid EHR Incentive Program and indicates the program is healthy and growing steadily.

The 2013 data from the annual National Ambulatory Medical Care Survey are encouraging:

Nearly 80% of office-based physicians used some type of electronic health record system, an increase of 60 percentage points since 2001 and nearly double the percent in 2008 (42%), the year before the Health Information Technology and Economic and Clinical Health Act passed as part of the Recovery Act in 2009.
About half of office-based physicians surveyed said they use a system that qualifies as a “basic system,” up from just 11% in 2006.
Almost 70% of office-based physicians noted their intent to participate in the EHR incentive program.

Figure 1. Percentage of office-based physicians with EHR systems: United States, 2001-2013

The report also noted that 13% of physicians who responded said they both intended to participate in the incentive program and had a system that could support 14 of the Meaningful Use Stage 2 “core set of objectives,” ahead of target dates. This survey was performed in early 2013 – before 2014 certified products were even available.

In Praise of Lisa Bonchek Adams, Breast Cancer Expert

Jan 16, 2014• 4

By Brian Loew

The two columns by Bill and Emma Keller about Lisa Bonchek Adams unleashed fury this week from supporters who questioned the manner in which Adams, who has metastatic breast cancer, “lives her disease” through her blog and Twitter feed.

Amid reams of articles, blogs, tweets and Facebook posts, patient advocate and breast cancer survivor posted Liza Bernstein grabbed our attention for posting a brilliant yet simple observation. Responding to an article in Gigaom, Bernstein noted that Bill Keller wrote this of Adams:

“Her digital presence is no doubt a comfort to many of her followers. On the other hand, as cancer experts I consulted pointed out…”

And Keller went on to describe what those experts thought.

Bernstein and other e-patients know well that Lisa Adams is an expert. In her response, Bernstein said that while Adams “is not a doctor or a researcher, [she] is a highly engaged, empowered, and educated patient who, as far as I know, has never shared her story lightly.”

Perhaps unintentionally, Keller’s supposition that Adams is a “comfort” to other patients compared with the analysis he provides from “cancer experts” marginalizes what people like Adams bring to others affected by cancer.

Fee for Service vs. Fee for Serving

Jan 15, 2014• 15

By Robert McNutt, MD & Nortin Hadler, MD

In a previous blog we demonstrated how guidelines can compromise the care of individual patients when designed to serve the health care system.

Why should treating physicians defer to guideline committees at all, we asked? For decades medical students have been taught to read and understand information from published papers.

We are all trained in critical appraisal and can keep up with the clinically meaningful literature, the literature that is relevant and accurate enough to present to patients. Just because there are nearly 20,000 biomedical journals does not mean that any, let alone all are replete with meaningful information. We can discern the valuable from the not valuable; why do we need others to tell us?

In fact, we even argued in our last post that patients can and should judge the value of medical information. After all, they face the consequences of misinterpreting the likelihoods of benefit and of harm associated with various options for care.

No one remembers the numbers that describe the chances for benefit and harm or ask more questions about the veracity of information than a patient who must choose. The smartest information managers we have ever encountered are our patients; when informed, they quickly determine the validity of the information and apply their personal values to the estimations of the chances for benefit and harm.

Patient Empowerment

Take the example of a patient who recently entered into a therapeutic dialogue with one of us, RAM. This was not the traditional clinical interview. This patient had been diagnosed with prostate cancer and was scheduled for an approach to treatment that the diagnosing physician had offered as the most sensible. However, the decision did not rest easily.

The appointment with RAM was scheduled because the patient sought a dialogue that might offer a chance to reflect on the rationale for the approach he was about to initiate. Two hours into the dialogue, the patient, a 40ish year old African-American man accompanied by his wife, were mulling over the marginal benefits and harms of the options for treating an early stage prostate cancer.

The wife asked how many African-Americans were in the study under discussion. “None”. The husband perked up and then asked, “How many people in the study was my age?” “None”. They then asked if the difference in benefit was a certain, fixed amount? “No, it varies over this range.” – examining the descriptive statistics.

They then asked when the study was started and did it pertain to the present day. “It started over 15 years ago” and the stage of disease of the men in the study was generally more aggressive than in this particular case.

Dr. Aetna Will See You Now

Jan 15, 2014• 14

By Al Lewis & Vik Khanna

The ever-blurring line between the practice of medicine and the business of profiting from unhealthy lifestyles was crossed again Wednesday, as Aetna announced a collaboration with two pharmaceutical companies to pitch their prescription weight loss drugs to selected Aetna members.

This announcement crosses multiple lines, not just one. First, no insurer has ever announced that it would openly direct a specific class of members to use particular proprietary drugs. Disease management (DM) programs rarely recommend specific drugs, and certainly in the exceptionally rare instances when they do, the recommendations are not specific brand-name drugs (in this case, Arena’s Belviq and Vivus’s Qsymia).

Instead, DM focuses on improving compliance with existing drug regimens, and DM firms encourage members “talk to their doctor” about changing therapies. While DM companies shy away from directing patients to specific products, physicians and pharmacists have discretion to discuss the full range of covered generic and brand products with patients, in order to optimize therapy and close algorithm-identified care gaps.

Second, there are no generally accepted care algorithms (other than those created by the manufacturers of those products) for these two drugs in the treatment of obesity. So there is no “gap” to fill. If there were an accepted protocol, these drugs might be blockbusters but instead Belviq’s recent quarterly sales were an anemic $4.8-million, “well below even reduced Wall Street expectations,” while QSymia sales are “flailing” at $6.4-million for the same period.

Obese people and their physicians seem to be avoiding these drugs in droves. Regardless of what Aetna and the manufacturers believe about their effectiveness, or whatever promotional deal they’ve cut, market reaction is telling a different story, and unfortunately for Aetna, Vivus, and Arena we live in a market economy.