The Health Care Blog – Page 508 – Everything you always wanted to know about the Health Care system. But were afraid to ask.

Above the Fold

How Health Plan Risk Adjustment Models May Change Under the ACA

Jan 3, 2014• 4

By KIP PIPER

Risk adjustment is a key mechanism to ensuring appropriate payments for Medicare Advantage plans, Medicare Part D drug plans, and Medicaid health plans. Since health plans vary in their mix of healthy and sick enrollees, risk adjustment modifies premium payments to better reflect the projected costs of members served and compensate plans that enroll high-cost patients.

Historically, risk adjustment was only used in Medicaid and Medicare – in effect, redistributing some revenue from health or drug plans with a relatively healthier mix of members to those plans with a more costly enrollment profile. However, the Affordable Care Act (ACA) extends risk adjustment to the individual and small group health insurance markets starting in 2014.

A new brief from The Synthesis Project tackles the issue and makes several interesting recommendations for how to improve risk adjustment methods for the post-ACA market. Without accurate risk adjustment, health plans have a strong financial incentive to seek out only the healthiest enrollees, especially under ACA-mandated adjusted community rating. Under adjusted community rating, health plans may not vary premiums based on health status or sex and are limited in how much they may vary premiums based on age. Under ACA, the healthy, the young, and men subsidize the health costs of the unhealthy, the older, and women.

Risk adjustment is therefore a necessary factor in stabilizing the dramatically new post-ACA health insurance marketplace, particularly the new Health Insurance Exchanges. Even then, the ACA is a giant game of musical chairs. The market under ACA will be chaotic and challenging, with a mix of winners and losers once the music stops and the dust settles, which will take at least three to five years.

Headlines You’ll See in 2014

Jan 2, 2014• 59

By Paul Keckley

Affordable Care Act major issue in Campaign 2014; ‘fix and repair’ new focus. ObamaCare will be the defining issue in the coming election cycle, but the political debate will not be Healthcare.gov glitches or enrollment.

Rather, the issue will be sticker shock in insurance premiums and the complaints from doctors and hospitals that they’re being driven out of business. “Repeal and Replace” will not be heard; the new slogan will be ‘fix and repair’ for both friends and foes of the ACA.

Hospitals battle for survival. Faced with negative operating margins, sequester cuts and mounting bad debt, state and local officials and hospital boards will take dramatic steps to insure acute services survive. Some will merge local hospitals to be operated as a public utility.

Some academic medical centers will spin off their research enterprises into commercial ventures with bio-pharma and device partnerships. Some will merge or sell out to larger systems with stronger balance sheets.

And all will reduce operating costs and purge clinical programs no longer affordable. As patient demand and their severity increase, hospitals will operate their inpatient business as a cost center, and their enterprises as regional care management organizations assuming risk for costs, outcomes and safety. But none is delusional: hospitals face a battle for survival.

Physicians go it alone; holy war for future of the profession taking shape. Led by the American Medical Group Association and several specialty societies, large medical groups will join forces to advance a physician-centric platform for health reforms that protect physician-patient relationships, position primary care physicians as gatekeepers, and assume financial and clinical risk in contracts with insurers and employers via fully integrated health plans operated by the group.

Physicians will step up their political activism in 2014, armed with data showing their net incomes have suffered and their clinical autonomy compromised since the onset of health reform. In 2014, they’ll wage unsuccessful battles for replacement of the SGR and liability reform again.

And they’ll dust off advocacy advertising campaigns to drum up resentment of market pressures that threaten to deduce their profession to a guild employed by plans or hospitals. For doctors, 2014 will look like a last stand for the profession.

Occupy Health Care Breaks out; profits with purpose sought. Income inequality in the U.S. will spill over into health care in 2014. The social media fueled visibility of earnings and executive compensation in every sector of health care will spark local political activism.And interest in a single payer system will begin to build heading into the 2016 election cycle.

Just as value will be challenged, so will the morality of the U.S. health system, and a populist campaign to align profit with purpose sought.

An Epic Fail for Massive Open Online Courses?

Jan 1, 2014• 2

By MICHAEL B. HORN

Coursera, the popular massive open online course (MOOC) platform, intrigues. With over 5 million students served and $85 million raised—both numbers are first among the “MOOC platforms”—it’s the type of company that captures the imagination of people in Silicon Valley who dream of transforming sectors.

Its reach and emerging focus on K–12 professional development were prime reasons that we at the Clayton Christensen Institute, along with the Silicon Schools Fund and the New Teacher Center, recently offered a MOOC on blended learning through Coursera.

But Coursera has always given me reason to pause as well. It’s never felt to me like its initial incarnation could possibly disrupt higher education. Why? As I’ve told its team, offering courses from the top universities online and claiming that at last, anyone anywhere can access the best learning in the world isn’t correct.

The reason is that the top universities do not offer the best teaching and learning experiences. Instead, their faculty members are incentivized heavily to focus on research at the expense of teaching. If a professor seeking tenure at one of these institutions receives a teaching award, it is often said that that professor has just received the kiss of death for her tenure hopes. If students learn at these institutions, it’s often not because the teaching is so good, but because the students are so talented that they can absorb anything thrown at them (and it’s worth noting that just because a professor is entertaining, does not mean it’s a good learning experience).

Putting these courses online often makes them worse. Not only do professors not know how to teach well in person, but also their lack of understanding of the basic principles of sound learning design causes them to exacerbate these problems as they put these experiences online, which can become more problematic as students from all walks of life with many different learning needs are now theoretically able to take these courses.

How Can Patients on Medicaid Possibly Be Worse Off than Those Who Don’t Have Insurance?

Dec 31, 2013• 94

By Saurabh Jha, MD

“Extraordinary claims require extraordinary evidence,” said Carl Sagan.

The claim that health insurance improves health outcomes is hardly ground breaking. Studying whether insurance affects health status is like wondering whether three meals a day lead to a higher muscle mass than total starvation.

Well that’s what I thought. Until I read the study on Oregon’s Medicaid program by Baicker and colleagues in the NEJM earlier this year and, more recently, Avik Roy’s short treatise “How Medicaid Fails the Poor”.

Baicker et al found that Medicaid enrollees fared no better in terms of health outcomes than those without insurance. That is, no insurance no difference.

The study is an exemplar of policy research laced with regression equations, control of known confounders and clear separation of variables. There is only so much rigor social science can achieve compared to the physical sciences. Yet this is about as good a study as is possible.

The one thing the study did not lack was sample size. It’s useful to bear in mind sample size. Large effects do not need a large sample size to show statistical significance. Conversely, if study with a large sample size does not show even a modest effect, it means that the effect probably does not exist.

There are several interpretations of the Medicaid study, interpretations inevitably shaped by one’s political inclination. The ever consistent Paul Krugman, consistent in his Samsonian defense of government programs against philistines and pagans, extolled critics of Medicaid as “nuts” and asked, presumably rhetorically, “Medicaid is cheaper than private insurance. So where is the downside?”

Unlike Krugman I am not a Nobel laureate and am about as likely to win a Nobel Prize as I am of playing the next James Bond, so it’s possible that I am missing something blatantly obvious. Could the downside of a government program paying physicians, on average 52 cents, and as low as 29 cents, for every dollar paid by private insurance in a multiple payer system be access?

Indeed, it’s darn impossible for patients on Medicaid to see a new physician. As Avik Roy explains “…massive fallacy at the heart of Medicaid….It’s the idea that health insurance equals healthcare”.

But wait. It gets better.

I am accustomed to US healthcare throwing more plot twisters than Hercule Poirot’s sleuth work. But one I least expected was that patients on Medicaid do worse than patients with no insurance (risk-adjusted, almost). I am not going to be that remorseless logician, which John Maynard Keynes warned us about, who starting with one mistake can end up in Bedlam, and argue that if you are for Medicaid that is morally equivalent to sanctioning mass murder. Rather, I ask how it is possible that possessing Medicaid makes you worse off than no insurance whatsoever.

To some extent this may artifactually appear so because poverty correlates with ill health, and studies that show Medicaid patients faring worse than uninsured, cannot totally control for social determinants of health.

The Hospice Will See You Now

Dec 31, 2013

By John Schumann, MD

Doctors are asked to sign things all the time: Prescriptions, home nursing care plans, death certificates, diabetic shoe forms.

Less frequently, hospice verifications.

Why was I asked to sign hospice orders for Mr. Taylor? Sure, he was old. Eighty-seven.

He’d survived decades of high blood pressure, two major surgeries, unintentional weight loss, chronic pain, headaches, even a benign brain tumor. But I had never referred him to hospice.

I wouldn’t have diagnosed him as “terminal,” i.e. expected to live six months or less. As far as I could tell, he’d just keep on truckin’ for another year or three.

So why was I being asked to sign hospice paperwork for him? How did this come about?

“Mr. Taylor, why are you in hospice? Are you dying?”

-Not that he knew of. He’d just been told that he’d get more ‘home services’ that way.

“Who set this up for you?”

-It was one of those “home doctors.” Geriatric care providers that offer house calls to infirm seniors when it’s too hard for them to come to a doctor’s office.

Thing is, he was still plenty able to come to my office. And did so regularly.

Apparently, though, the opportunity to get more home services was too good to pass up.

The agency that was providing him at-home medical services referred him to a for-profit hospice firm–one that could collect the daily Medicare fee for a hospice enrollee.

Is it any wonder, then, that we’ve seen a surge in hospice enrollments in the last few years?

Finally, someone has written something about it. Thank you, Washington Post.

John H. Schumann, MD (@GlassHospital) is a general internist and medical educator at the University of Oklahoma School of Community Medicine in Tulsa, OK . He is also author of the blog, GlassHospital , where this post originally appeared.

Healthcare.Gov’s Numbers at the Deadline

Dec 30, 2013• 32

By Robert Laszewski

After the disastrous launch of Obamacare the enrollment of 1.1 million people in the 36 state exchanges run by the feds is a major accomplishment. It is likely that the enrollment in the 14 state-run exchanges will take total Obamacare’s private insurance enrollment to near 2 million for the year.

Does this mean that Obamacare is finally on track and moving toward success?

At least the front-end of HealthCare.gov is now clearly working.

I will suggest there are still some very important questions for Obamacare that need to be answered.

First, how many of these new enrollments are people whose policies have been cancelled under Obamacare?
As I have said on this blog before, I expect at least 80% of those in the existing individual health insurance market to lose their coverage by the end of 2014. Half of the market bought their coverage after March 2010 and therefore cannot continue while most of the other half of the market will not qualify under the Obama administration’s stringent grandfather rules.

What we don’t know is just how many of these people had to buy new coverage on January 1 given the widespread offers by carriers to “early renew” their coverage into late 2014. Then the President asked insurers and states to allow people to keep their coverage another year. It appears about two-thirds of the states went along with that request. Then many of the cancellations won’t occur until they renew throughout calendar year 2014.

We do know that California did not allow insurers to continue coverage for another year leading to 800,000 cancellations on January 1 and 200,000 cancellations by March. The state exchange has said that 300,000 of these are subsidy eligible and they can only get a subsidized policy on the exchange.

California will likely announce they have signed-up about 600,000 people this year. But given the cancellations that are occurring by January 1, is this a big accomplishment?

Washington State cancelled 260,000 policies and also did not allow the cancelled policies to continue past January 1. Half of these polices are subsidy eligible and can only get a subsidized policy in the state insurance exchange. Washington State might report 100,000 private plan enrollments by year-end. But if they cancelled 130,000 people who can only get a subsidized policy in their exchange, is this a big accomplishment?

The good news is that Obamacare will likely enroll almost 2 million people in 2013.

Even if we ignore that fact that many of these people were previously insured and had to replace cancelled policies (there were more than 400,000 subsidy eligible cancellations in California and Washington alone), 2 million people are only 10% of the 20 million uninsured in the U.S. who are eligible to buy coverage in the health insurance exchanges.

Why You Shouldn’t Succumb to Defeatism About the Affordable Care Act

Dec 29, 2013• 22

By Robert Reich

Whatever happened to American can-do optimism? Even before the Affordable Care Act covers its first beneficiary, the nattering nabobs of negativism are out in full force.

“Tens of millions more Americans will lose their coverage and find that new ObamaCare plans have higher premiums, larger deductibles, and fewer doctors,” predicts Republican operative Karl Rove. “Enrollment numbers will be smaller than projected and budget outlays will be higher.”

Rove is joined by a chorus of conservative Cassandra’s, from Fox News to the editorial pages of the Wall Street Journal, all warning that the new law will be a disaster.

Robert Laszewski, president of Health Policy and Strategy Associates, anticipates a shortage of doctors. “There just aren’t going to be enough of them.”

Professor John Cochrane of the University of Chicago predicts the individual mandate will “unravel” when “we see how sick the people are who signed up on exchanges, and if our government really is going to penalize voters for not buying health insurance.”

The round-the-clock nay-saying is having an effect. Support for the law has plummeted to 35 percent of those questioned in a recent CNN poll, a 5-point drop in less than a month. Sixty-two percent now say they oppose the law, up four points from November.

Even liberal-leaning commentators are openly worrying. On ABC’s “This Week,” Cokie Roberts responded to my view that the law eventually would prove popular by warning of “a whole other wave of reaction against it” if employers start dropping their insurance.

Some congressional Democrats are getting cold feet. West Virginia Senator Joe Manchin recently fretted that “if it’s so much more expensive than what we anticipated and if the coverage is not as good as what we had, you’ve got a complete meltdown.”

Get a grip.

If the past is any guide, some fixes will probably be necessary – but so what? Our current healthcare system is the real disaster — the most expensive and least effective among all developed countries, according Bloomberg’s recent ranking. We’d be collectively insane if we didn’t try to overhaul it.

Why the January 1st Deadline Matters

Dec 27, 2013• 37

By Seth J. Chandler

Contrary to the views of some, the number of people who have insurance coverage through the Exchanges as of January 1, 2014, matters to everyone. It matters because the pool that exists on that date will determine, at least for a while, whether the premiums charged by insurers in the Exchange are likely to be stable and the extent of the federal government’s multiple obligations to subsidize plans purchased on the various Exchanges. It is not as if insurers get a claims paying holiday simply because more and healthier people may enroll later in the year.

It also matters because a major point of the Affordable Care Act was to increase in an efficient and relatively painless way the net number of people who have insurance or social protection against significant illness. If the numbers in the Exchanges and in the expanded Medicaid program do not way more than offset the number of persons who lose their insurance as a result of the ACA, or if the cost of extending health protection in this fashion proves too high, the ACA will not have accomplished its goals.

Given the chaos that has erupted as procrastination strains Exchange infrastructure and deadlines are repeatedly extended, it is difficult to tell right now whether the ACA is performing as hoped. A few things are clear, however. The first thing is that the Obama administration is not releasing the sort of information from which an objective assessment could be made.

Platitudes such as “Millions of Americans, despite the problems with the website, are now poised to be covered by quality affordable health insurance come New Year’s Day,” from President Obama at his last press conference are just not a substitute for knowing how many people have enrolled in the plans in the various Exchanges, and more importantly, have paid for coverage. What are their ages? How about some real numbers as a Holiday present?

Second, the Obama administration is acting as if a large number of enrollees in the aggregate is the measure of success. This is simply not true. Putting aside the problem of it being paying customers rather than mere enrollment that ultimately matters, meeting or exceeding projections in some states does not compensate for deficiencies in many other states.

Because the pools are state-based, Texas insurers and insureds are not helped if enrollment in New York or Connecticut exchanges ultimately equals or exceeds targets. The insurance market in Texas and many other states will still be unstable with some insurers likely pressing for significant premium increases, contemplating withdrawal from the Exchanges, and demanding larger subsidies from the federal government via Risk Corridors and other programs.

They’re Not Deadlines. They’re Opportunities …

Dec 26, 2013• 54

By DAVID BLUMENTHAL, MD

Confusion about Affordable Care Act (ACA) deadlines is rampant. That’s because there are lots of them and they keep changing. The fact is that some of them matter a lot more than others.

In my view, the BIG deadline is:

MARCH 31, 2014: Under the ACA, all Americans must have health insurance, and this is the latest date you can acquire it if you wish to avoid paying a penalty on your 2014 income tax. Some individuals will be exempt from penalties, including, as of last week, people whose policies were canceled because their plans’ benefits did not meet new ACA standards of adequacy.

Another date that has drawn attention but, in my view, doesn’t matter as much:

JANUARY 1, 2014: This is not a deadline so much as an opportunity. It is the first day, when, if you signed up in time (now December 24 for the federal website, but a few states have later deadlines)—and paid your premium in time (at the administration’s urging, many insurers are allowing a grace period through January 10 for the federally run marketplaces and some states have also moved this date)—you could enjoy the subsidized coverage available under the ACA. But if you miss these so-called deadlines, you still have until March 31 to sign up for coverage to avoid a penalty.

For the millions of Americans who are uninsured, or who could have enrolled in improved insurance through a state or federal exchange, missing these deadlines merely means you failed to make yourself better off as soon as you possibly could. BUT YOU WILL BE NO WORSE OFF THAN YOU WERE BEFORE.

There are also some dates that are consequential, but have received less attention, or have receded from the headlines:

NOVEMBER 2014: This is when the Obama administration promises online enrollment for the Small Business Health Options Program (SHOP) in the 34 states where the federal government is operating the small-business marketplaces for companies with fewer than 50 workers. For now, small businesses in these states can apply via paper application or an insurance broker or navigator.

Online access is available already in most of the 17 states and the District of Columbia that are operating their own SHOP exchanges.

JANUARY 1, 2015: The date by which employers with 50 or more employees will become liable for a tax penalty if they are not offering health insurance that meets minimum standards, and an employee becomes eligible for subsidized private coverage through the marketplaces.

The changing dates associated with the ACA are troubling to some, since they suggest confusion and even mismanagement by the Obama administration. It would obviously be reassuring if every declared date were honored and announced rules and intentions never changed.

On the other hand, I’m doing some long-delayed repairs in my home. The contractor said the work would be done by Thanksgiving, but there were unanticipated problems. We’re hoping now for Christmas. I’ll be happy if it’s done by mid-January, but the key thing is whether, a year from now, I’m satisfied with the result.

Health insurance is obviously way more important to millions of Americans than any home repair project could ever be. But few things in life go exactly as planned, and it would be totally astonishing if the implementation of massive reforms to a sector accounting for 20 percent of our economy rolled out without a bump or a detour. We should keep that in mind as we think about those changing ACA deadlines.

David Blumenthal, M.D., M.P.P., is president of The Commonwealth Fund, where this post originally appeared.

The Doctor Who Played With Fire

Dec 24, 2013• 3

By Hans Duvefelt, MD

The corpse, laid out on a gurney and covered with a white sheet, was wheeled onto the stage by two women in long, white lab coats. A middle aged man with a bow tie welcomed us, the incoming class of the spring semester, to Uppsala University and the Biomedicine Center, where we would spend the next two years in “pre-clinicals”, until we knew enough to start our three and a half clinical years at the Academy Hospital.

The Biomedicine Center was almost brand new, a glass and concrete labyrinth with a large sculpture depicting Watson and Crick’s DNA molecule by the front entrance. The vast complex lay near S-1, the Uppsala military regiment. The brick buildings diagonally across the street were very familiar to me as the place where I had met the biggest failure in all my twenty years only months before.

As I sat in the large lecture hall with the corpse on the stage, I glanced over at L., my buddy from the Swedish military’s elite division, the Interpreter School, where we had also sat next to each other on the first day, when the Captain in charge told us:

“Soldiers, you may all have been the smartest kids in your school, but it’s different here. Most of you won’t make it, and will be culled over the next two months. The Interpreter School accepts eighty recruits and graduates twenty to twenty-five. If you don’t have what it takes, don’t waste our time or yours!”

L. and I had both thought that learning Russian would be a neat way to spend our compulsory year and a half in the military, but just barely more than a month after that harsh introduction, we were both on our way back to our respective home towns to figure out what to do until we would be able to start medical school. Our military service was put on hold until we could return as medics.

The man with the bow tie went on to introduce our guest professor, on loan from the University of Bavaria. As we all knew, the Germans have been the greatest anatomists since the last century, and all of us had already been to the University book store to purchase Haeffel’s “Topografishe Anatomie”, which would be our constant companion for the next five months.