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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.

What Exactly Are Insurers Canceling? And Why?

Dec 23, 2013• 2

By THCBist

A THCB reader in New York writes in:

There is one aspect of the ACA that isn’t being discussed a lot, but is pertinent to the future landscape of health care in this country — the extent to which the ACA is causing a sort of reset, or wiping of the slate, when it comes to insurance policies and procedures.

Previously, there were multiple insurers and multiple policies, many of which had been around for a long time. If an insurer wanted to suddenly change providers in its network, ratchet down provider reimbursement, alter covered procedures or make other adjustments, this was feasible, but too much of a change would entail an outcry limiting insurers’ freedom of action. The overall system had a certain air of stability or inertia, making any changes stand out, any big changes cause for scrutiny and possibly rebellion.

Now, with the ACA, everything is being tossed up in the air and when things land, much can and will be different. Some changes are mandated by the ACA, such as minimum coverage, and insurers are cancelling inadequate policies, substituting very different ones. But even when a policy doesn’t need to be changed, insurers will justify change by pointing to the ACA.

“Given the requirements of the ACA, we must make certain changes to your policy. In particular…”

We are at the beginning of a totally new insurance landscape, even if most of the insurers remain the same. The public has been primed to expect major change and insurance companies will certainly make use of this expectation.

The result is likely to be more restrictive networks, decreased reimbursements to providers and other measures to limit cost. Everything is now up for grabs.

If you have questions about the Affordable Care Act or your buying insurance on the federal state exchanges, drop us a a note. We’ll publish the good submissions.

Caveat User: Understanding the Health Risks of Mobile Devices

Dec 23, 2013• 9

By DAVID KATZ, MD

Tis the season to, well, buy stuff. Increasingly, the stuff we buy is electronic. In fact, not only that, but increasingly the stuff we buy with is electronic, too. We are using gizmos to shop for gadgets, or possibly gadgets to shop for gizmos.

In any event, we are ever more frequently in the company of the energy fields our electronic devices, and in particular our smart phones, generate. This deserves more attention than most of us accord it.

Don’t get me wrong — I am not suggesting we return to the pre-cell phone days when we lived in dark caves. We are fully ensconced in the electronics era, and there appears to be no going back. I am as fully dependent on electronic devices as anyone, and maybe more than most, living much of my life these days online. Like so many, I am both beneficiary and victim of the attendant efficiencies. On the one hand, I can’t recall how we ever got anything done in the days before instantaneous communication and push-of-a-button document transmission.

On the other, I do long for the freedom of the time before an unending stream of emails became my manacles. I did sleep better in the days before bedtime meant checking one last time to see who in the world needed what, and/or finding out that someone in cyberspace thinks I’m a moron. Oh, well.

Some of the risks related particularly to mobile phone use are well known. The dangers of distracted driving are common knowledge, with cell phone use now implicated in at least 25 percent of all car crashes. There is some evidence that ambient levels of empathy — our ability to understand and connect to one another’s emotional state — are declining, and possibly due to the frequency with which technology comes between us. A recent study among college students finds that more frequent use of cell phones correlates with impairment of academic performance, and increased anxiety — although the study could not prove cause and effect.

But the greatest and most insidious risk of cell phone use pertains to the electromagnetic fields of non-ionizing radiation they produce. What makes this risk insidious is our potential to dismiss it altogether, in part because it is convenient to do so, and in part because it’s hard to take seriously a potential menace that is totally invisible. I suspect we are all at least somewhat prone to a “what I can’t see, feel, taste, smell or hear can’t hurt me” mentality.

But of course, that’s clearly wrong, as we all have cause to know. Anyone who has ever had an X-ray has experienced first hand the power of an invisible force, in this case ionizing radiation, to penetrate deeply into our bodies. Anyone who has had a MRI has experienced the capacity of non-ionizing electromagnetic fields to do the same. What we can’t see or feel can, in fact, reach to our innermost nooks and crannies, both to produce vivid images of our anatomy — and exert other effects.

N = 1 My Experience with the New Health Care System

Dec 22, 2013• 88

By Robert Fogerty, MD

“You look nice today. People don’t come to chemo in suits very often.”

The friendly and familiar receptionist mentioned as I was checking out, the always full jar of lemon flavored hard candy on the shelf between us. As I pocketed a few of the candies, I managed to swallow the nausea and metallic taste just enough to say, “Thanks. I have a job interview today.”

During my senior year in college, with medical school acceptance letter in hand, I was diagnosed with metastatic testicular cancer. Initially, life became planning surgery and meeting doctors, but early in my treatment course I received a letter that my health insurance had been exhausted and I would no longer receive any health benefits. This was after my first of four chemo cycles, with a major surgery still to come. Needless to say, this was a problem. My parents were both well educated, a lawyer and a chemist-turned-teacher, but this took everyone by surprise and presented a new crisis.

We responded by dividing up tasks. My parents quickly inventoried all the assets, including the family home, and my sister called around to all the hospitals to see what could be done. She called the local and state governments asking for advice while I simply tried to eat food and get to class to graduate on time; I couldn’t have another tuition bill on top of my health expenses. I also started to look for a job, with a job came insurance – this much I knew.

I went to the interview, a job as a management trainee in a car rental agency, with hopes that this job would be something I could get, could do during treatment, and would provide the insurance that would save my family from financial ruin at my hands – my disease. I went to a Jesuit college and learned that truth and honesty are paramount. So, I told the recruiter that I had cancer, I was in treatment, and that I would likely be done soon – all true.

I didn’t get the job. I still didn’t have insurance and my next chemo session, with its massive bill, was coming very quickly.
My sister learned that this would not be fun. One hospital said to her that they would treat me and then take us to court to get paid. Thankfully, I went to school in Massachusetts where a law was on the books that allowed me to enroll in health insurance without a pre-existing condition exclusion because my insurance being exhausted counted as a special qualifying event. I enrolled in an individual insurance plan, my care went uninterrupted, and I graduated on time. To this day, my sister and I remain grateful to Massachusetts for that single law, which is as much a part of my success as cisplatin and etoposide, the chemotherapy agents I received.

The bills still mounted, but were manageable. I survived, personally and financially. I pushed off medical school for a few years to get my life back in order, and moved on. I had many scary moments during my treatment, from the plastic surgeon telling me my arm might need amputation to my neutropenic fever to being discharged just in time for my college graduation. However, what bothers me the most was, and stillis, the sense of abandonment from my society when my insurance ended.

The Obamacare Slippery Slope–What’s Your “Hardship?”

Dec 20, 2013• 33

By Robert Laszewski

As of this morning, here are the new rules.

If you had a health insurance policy that was cancelled, you are now exempt from the individual mandate and its tax penalty should you not decide to buy a replacement policy. In addition, you can now sign up for the very high deductible Catastrophic Plan that was originally reserved only for those under the age of 30.

If you did not have a health insurance policy that was cancelled, you are still subject to the individual mandate and you are not entitled any special treatment toward signing up for the Catastrophic Plan. You must pay the full price for an exchange plan and accept whatever out-of-pocket costs and network limits it might have for the money.

The administration made this change under the “hardship” provisions already part of the law. They have simply defined hardship as having lost your old individual plan and your not being able to find something without it being a “hardship” to purchase, presumably over price or coverage.

This change was brought about when a number of Democratic Senators, some of them facing a tough reelection battle, demanded this concession.

The change was made without consulting the health insurance industry and it was a surprise to them. It is another Obamacare change months after their 2014 rates were set under the presumption all of these cancelled policyholders would be paying a lot more premium into the pool than they pay today.

One has to believe this will not be the last concession to Democrats under reelection pressure.

One has to wonder how this can’t other than undermine further how people feel about Obamacare––particularly its fairness––and taking their “social responsibility” to sign-up seriously.

Healthcare Innovation Is Not Just About Cutting Costs

Dec 20, 2013• 7

By David Shaywitz, MD

Aspiring healthcare entrepreneurs could be forgiven for assuming our most significant challenge is the need to reduce the cost of care. Investors and policy wonks alike seem to agree on the overriding need to focus on innovations that will improve efficiency and take costs out of the system.

The appeal of this approach is easy to understand: rising healthcare costs are a real problem, and business process improvement feels like something we already know how to do. Large companies like GE and Oracle are thrilled by the opportunity to apply their process methodologies to healthcare. Management journals love the idea of improving healthcare through operational excellence. An increasing number of foundations have also joined the fray, focused explicitly on supporting innovations that reduce the cost of care.

Yet, as much as operational improvements are urgently needed, they should not represent the primary goal of healthcare innovation.

If we’re truly interested in high value healthcare, we’d do well to keep in mind that for many, if not most serious or chronic diseases, at least in the absolute sense, high value care simply isn’t an option. We have embarrassingly few therapeutic approaches that can really do much to restore the lives of these patients. Sufferers afflicted with Alzheimers Disease, pancreatic cancer, brain tumors, and so many other conditions desperately require transformative breakthroughs, not the mucking around the edges that passes for treatment today.

Make no mistake: it’s critical we do the very best we can to provide compassionate, evidence-driven care for patients who are sick right now, and innovations that contribute to the identification and humanistic delivery of the best available care are vitally important.Continue reading…

Sense and Sensibility on Hypertension

Dec 19, 2013• 17

By Vik Khanna & Al Lewis

Every now and then even blind squirrels find acorns. The medical care industry, which long ago abandoned sensible fiscal and therapeutic restraint in the quest for new patients, finally treats us to a revised hypertension guideline that thoughtful people can conclude makes a great deal of sense. It is even based on evidence, or actually the lack of it, which is itself a startling admission of reality from an industry that dances around truth with a nimble sophistry envied by even the most mendacious politicians.

The hypertension guidelines are a sharp departure from last month’s cholesterol guidelines, produced by a supposedly equally august panel of “thought leaders” who gave us guidelines that seemed to channel the The Talking Heads quite literally. John P. Ioannidis, along with Nortin Hadler, easily one of the two or three most important physician thinkers of this or any generation, wrote that the cholesterol guideline will be either…”one of the greatest achievements or one of the worst disasters of medical history.”

If you haven’t read the hypertension guidelines, here is a useful summary:

we treat too many people today;
we rely too much on drugs for things that drugs cannot fix;
treatment frequently does not produce health because therapy aims at a point, while the pursuit of health is a matrix; and
if we are really going to improve cardiovascular health, which is strongly implicated not just in stroke, heart disease, and kidney disease, but also cognitive health, people are going to have to change behaviors because there aren’t enough pills on the planet to fix what ails us.

Cognitive health is an especially useful guidepost, because contrary to popular myth, it isn’t something that mysteriously disappears in nonagenarians. The seemingly age-related decline is more likely the manifestation of damage done by a lifetime of incremental harms. Isn’t it edifying to have scientists catch up to our moms?

The new guidelines leave us a redefinition of high blood pressure: greater than 150/90, except in cases where a comorbidity compels pursuit of 140/90 or lower to prevent end-organ damage. This has implications not just for medical care but for workplace wellness, which obsesses with hypertension when it is not obsessing with cholesterol and glucose.

The hypertension guidelines yank away from workplace wellness vendors yet another reason to fine or otherwise antagonize employees who don’t show up at health fairs. The progression of hypertension is strongly related to aging, and healthy aging is the most reliable bulwark against premature stroke, heart attack, kidney failure, or dementia. Unless workplace wellness vendors plan to follow people into retirement, which is when the overwhelming majority of heart attack, stroke, and dementia occurs, there is no logical reason to ask any employee what his or her blood pressure or deign to tell them how to address it.

What We Don’t Know Can Hurt Us

Dec 18, 2013• 32

By David Dranove & Craig Garthwaite

As the health insurance exchanges find their footing and potentially millions of Americans gain access to insurance, this may be a good time to step back and take a longer term view of the ACA. When you get down to it, expanding health insurance coverage was the easiest and least controversial part of health reform. There is no shortage of ways to expand health coverage and almost any credible health reform proposal would have done the job, provided enough money was thrown at the problem.

In designing the ACA, perhaps as a result of political pressure, President Obama opted for a combination of heavily subsidized individual insurance exchanges and generous expansions of Medicaid. Freed from political constraints, he might have instead pushed for the single payer system that many of his most ardent supporters desired. Republicans inclined to expand coverage (at least one of us is proof that unlike the unicorn these do exist) might have pushed for a pure voucher program that harnessed market forces.

All of these options would expand coverage to the degree that policymakers were willing to fund them. So while we congratulate the President for his political success (we doubt the other options could have made it through Congress), it is a simplistic mistake to evaluate the implementation of the ACA by counting the numbers of uninsured or waiting for the monthly updates on the enrollment figures from the exchanges website. Any regulator with a big enough purse can, in the fullness of time, expand access. Frankly, that’s the “easy” part of healthcare reform.

But what about the other elements of the so-called “triple aim” of health reform: cost and quality? You see, while we agree that liberal, moderate, and conservative health reforms can all improve coverage, they each will have very different effects on the other important outcomes. Consider for example the oft-discussed “Medicare for all”; i.e. a single payer system. This would increase access without the messiness of the exchanges. It would also allow the government to flex its monopsonistic muscles and quickly reduce costs – though likely at the expense of quality. In contrast, relying on markets may not reduce costs in the short run, and may not necessarily reward real quality (though it has a better short than single payer in this regard).

Evaluating health reform in the context of the “Triple Aim” is important, but even that approach is not nearly enough. There is a broad consensus among that technological change is the most important long run driver of cost and quality. It follows that the most important element of health reform is its impact on technological change.

To understand how technological change affects all of us, consider the profound impact of the top ten medical advances in the last ten years, as listed by CNN:

1. Sequencing the human genome
2. Stem cell research
3. HIV cocktails
4. Targeted cancer therapies.
5. Laparoscopic surgery