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How Will My Subsidy Be Paid?

• 13

By THCBist

A THCB reader writes in:

“I understand that part of the population will qualify for subsidies and others will not.

What I do not understand, nor do I think that those getting subsidies understand, is how will the monthly cost be paid.

For example (this is made up), the insurance I am quoted costs $1,200 per month, however, I qualify for a $500 per month subsidy.  When I pay the bill each month do I pay $1,200 or $700.   My understanding is that the ACA is showing people the Net cost with the subsidy applied.   I would assume that one would pay the full amount and hope to get the subsidy as a refund when taxes are filed.

Unfortunately, I can not afford to pay $1,200 per month up front and am unable to wait to file taxes and hope to get the refund in a timely manner.  Those that get subsidies are most likely lower paid, already struggling to make ends meet, and will be unable to pay the up front value.  How does the ACA work regarding paying the monthly costs?  What happens if a person is audited?  Does it delay their subsidy?

What happens if refunds are late?  How are people supposed to pay their bills if they are counting on the subsidy in their refund?

If those that do receive subsidies have to pay the entire cost up front, then this will turn into a very big cash flow issue for them.   Is this how the program works?  If the ACA Website is showing the net cost with the subsidy applied, however, does not clearly state that you pay the full cost up front and receive the subsidy with your tax refund, then I find that to be very shady advertising.”

Is Opposition to Obamacare Racist?

• 27

By PETER UBEL, MD

It is pretty easy to be against Obamacare these days.

The federal government can’t come up with a working website to help people buy health insurance. The President misled people about whether they could hold onto their old insurance plans. And come next tax day, the least popular provision of the Affordable Care Act – the individual mandate – will be implemented for the first time.

Lost amidst all this controversy is the very strong likelihood that once Obamacare is fully implemented, and the disastrous healthcare.gov website is functioning properly, the law will mean health insurance for millions of previously uninsured Americans.

And the people most likely to benefit from this law, according to a recent study, are blacks and Hispanics who not only have higher rates of uninsurance, but also frequently demonstrate greater need for medical care.

Which raises a question: is it racist to oppose the Obamacare efforts to increase health insurance in the United States?
Continue reading…

A Tale of Two IT Procurements

• 12

By David Blumenthal, MD

Recently, the President of the United States, the most powerful person on earth, the man whose finger rests on the nuclear button, struck a bold blow for . . . procurement reform?

“There are a whole range of things that we’re going to need to do once we get [the Affordable Care Act (ACA) rollout] fixed—to talk about federal procurement when it comes to IT and how that’s organized,” the president said on November 4, speaking to a group of donors and supporters.

People are clamoring for heads to roll, and the president is talking about what just could be the geekiest, most obscure topic ever to clog a federal bureaucrat’s inbox. Procurement reform? Has he gone off the deep end?

Well, not really. Among the causes of healthcare.gov’s difficulties, the federal process for purchasing goods and services could rank right up there with toxic politics, lack of funding for ACA implementation, and management goofs. Let me explain why, from personal experience.

From 2009 to 2011, I served as National Coordinator for Health Information Technology. My job was to implement the HITECH ACT, which aims to create a nationwide, interoperable, private, and secure electronic health information system. As national coordinator I had to lead a lot of federal contracts.

This is how that went.

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New California Numbers Show Disproportionate Enrollment by Those Over 55

• 20

By SETH J. CHANDLER

California has frequently been cited as an early Affordable Care Act success story with enrollment coming at least closer to projected numbers than in other states. This week’s release of information from Covered California, the state entity organizing enrollment there, shows a mixed picture about the likelihood that the ACA will become a stable source of non-discriminatory relatively inexpensive health insurance in the nation’s most populous state.

A highlight from the report is that 79,891 have at least gotten as far as selecting a plan since enrollment opened on October 1, 2013.  That’s better than any other state and better — at least as of the last report — of all the other states combined using the healthcare.gov portal.

And, because, contrary to the wishes of California Insurance Commissioner Dave Jones, Covered California has decided not to permit those with recently enrolled in underwritten individual health insurance to “uncancel” policies that do not provide Essential Health Benefits, there is the potential to add more people to the Exchange pools than would otherwise be possible.

Additional good news: the pace of enrollment has picked up over the past two weeks.

Still, to date, the 79,891 who have at least selected a plan are only 6% of the 1.3 million that the federal government projected California would enroll through 2014. And the web site in California appears to be working acceptably.

Continue reading…

What Is the Difference Between On-Exchange and Off-Exchange Policies?

• 26

By THCBist

A THCB reader from Colorado writes in:

“I am an individual health insurance purchaser in Colorado. I know I need to buy my policy through the Colorado exchange if I want to get a possible subsidy. I am not likely to be eligible for a subsidy, however, and I found that it’s also possible to buy policies “off” the exchange. I briefly looked at some of those policies and found similar premiums, copays, and deductibles to policies “on” the exchange. I assume the “off-exchange” policies must also be as ACA-compliant as the exchange policies. 

Given all these similarities, what is the DIFFERENCE between “on”-exchange and “off”-exchange policies?

In the ACA, what purpose do the two categories serve?”

Radiologist: Thou Shalt Disclaim by Law

• 12

By Saurabh Jha, MD

There is an old joke. What’s a radiologist’s favorite plant? The hedge.

Radiologists are famous for equivocating, or hedging.

“Pneumonia can’t be excluded, clinically correlate”. Or “probably a nutrient canal but a fracture can’t be excluded with absolute certainty, correlate with point tenderness”.

Disclaiming is satisfying neither for the radiologist nor the referring physician. It confuses rather than clarifies. So one wonders why legislators have decided to codify this singularly unclinical practice in the Breast Density Law.

The law requires radiologists to inform women that they have dense breasts on mammograms. So far so good.

The law then mandates that radiologists tell women with dense breast that they may still harbor a cancer and that further tests may be necessary.

You may quibble whether this disclaimer is an invitation or commandment for more tests, or just shared decision-making, the healthcare equivalent of consumer choice.

But it’s hard to see why any woman would forego supplementary tests such as breast ultrasound, magnetic resonance imaging and 3 D mammogram, or all three, when their anxiety level is driven off the scale.

What piece of incontrovertible evidence inspired this law, you ask?

Perhaps a multi-center trial run over 10-15 years that randomized women with dense breasts to (a) mammograms plus additional screening and (b) screening mammograms alone, show that additional screening saves lives, not just find lots of small inconsequential cancers.

No. The law was instigated by a heart-rending anecdote, which avalanched into the “breast density awareness” movement, cloaked by an element of scientific plausibility: women with dense breasts may have a higher incidence of cancer; a conjecture of considerable controversy.

Wasn’t  the Affordable Care Act (ACA) supposed to usher an era of rational policy-making, guided by p values, statistics not anecdotes?

Continue reading…

The Real Reason You May Not Be Able to Keep Your Doctor Under the New Healthcare Law

• 25

By Robert Laszewski


Here is what the President said at the American Medical Association Meeting in July, 2009––and likely lots more times:

“No matter how we reform health care, we will keep this promise: If you like your doctor, you will keep your doctor. Period. If you like your health care plan, your will keep your health plan. Period. No one will take it away. No matter what. My view is that health care reform should be guided by a simple principle: fix what’s broken and build on what works.”

We have all heard this repeated many times before in recent weeks. But with the front-page story in the Washington Post yesterday, “Health Insurers Limit Choices to Keep Costs Down,” it’s as if somebody rang a new bell this time focused on the “you will keep your doctor” part.

It’s not like we haven’t been talking about more narrow networks becoming a staple of the new health insurance exchanges.

It is as if some of this stuff is just starting to sink in.

Why the limited networks?

In the old health insurance market, insurers competed for business through price and plan design. Network size has historically been a minor factor with consumers and employer plan sponsors expecting to be able to use about any doctor or hospital, especially those with the best reputations.

But with the Affordable Care Act, health plans lost two of their historically big plan pricing variables; medical underwriting and plan design.

Under Obamacare, insurers can no longer underwrite, or exclude people, to keep the cost of their individual market health insurance plans down––a good thing.

Under Obamacare, insurers can no longer offer a wide variety of health insurance products in the individual health market––a good thing when it gets rid of the worst of the health plans out there but not such a good thing when it gets rid of the many policies people could choose and have liked and are now mad about losing. Now, all health plans have to fit into four strict boxes: Bronze, Silver, Gold, and Platinum. And, these boxes can only differ by out-of-pocket costs––not benefits.

So, if a health plan can no longer vary its benefit choices, how can it distinguish itself on price?

Continue reading…

The ePrognosis App: How Calculating Life Expectancy Can Influence Healthcare Decision-Making

• 6

By Leslie Kernisan, MD

Last month an intriguing new decision support app launched, created by experts in geriatrics and palliative care. It’s meant to help with an important primary care issue: cancer screening in older adults.

Have you ever asked yourself, when considering cancer screening for an older adult, whether the likely harms outweigh the likely benefits?

Maybe you have, maybe you haven’t. The sentence above, after all, is a bit of wonky formulation for the following underlying questions:

  • How long is this person likely to live, given age and health situation?
  • Given this person’s prognosis, does cancer screening make sense?

The first question seems like one that could easily occur to a person — whether that be a patient, a family member, or a clinician – although I suspect it doesn’t occur to people perhaps as often as it should.

As for the second question, I’m not sure how often it pops up in people’s minds, although it’s certainly very important to consider, given what we now know about the frequent harms of cancer screening in the elderly, and usually less frequent benefits.

Furthermore, there is abundant evidence that “inappropriate” cancer screening remains common. “Inappropriate” meaning the screening of people who are so unwell and/or old that they’re unlikely to live long enough to benefit from screening.

For instance, one astounding study found that 25% of physicians said they’d order colon cancer screening for an 80 year old with inoperable lung cancer. So it’s clear that improving the decision-making around cancer screening would help improve healthcare safety, quality, and value.

Continue reading…

Another Law Raising the Cost of Health Care

• 11

By Josh Tenzer

While there has been much focus lately on the ways in which ObamaCare is chilling the growth of private business, we should not overlook the continuing deleterious effects of the one surviving relic of HillaryCare, the Health Insurance Portability and Accountability Act (HIPAA). Quietly, September 23 came and went as the compliance effective date for a new rule, expanding the reach of HIPAA, and likely driving many smaller players out of the health care industry.

Spearheaded by then First Lady Clinton, HIPAA was established in 1996 to improve privacy of personal health information, referred to as protected health information, or PHI. It requires health care providers, known as “covered entities,” and their vendors, contractors, and agents with access to PHI, known as “business associates,” to comply with certain privacy standards under its “Privacy Rule,” and with certain security standards under its “Security Rule,” in order to protect sensitive health information that is held or transferred in electronic form.

Over the past decade, equipped with the noble aim of protecting our privacy, HIPAA has successfully demonstrated the power of the law of unintended consequences. Improved protection of PHI has been marginal. However, HIPAA has impeded communication among physicians, reduced physician time devoted to patient care, and deterred medical research. And all at an enormous cost of compliance. While estimates vary widely, the cost of compliance for many providers has been in the millions.

Now, rather than take heed, the government has decided to double down through expansion. Under the Health Information and Technology for Economic and Clinical Health Act (HITECH), a corollary of HIPAA, promulgated to create incentives to facilitate the development of healthcare information technology, the government has sought to update the requirements of HIPAA in light of the changing dynamics of technology and health practices, increasing the safeguards and obligations of health care providers and their business associates.

Continue reading…

The Next Shoe to Drop: Small Group Health Insurance Cancellations

• 24

By Robert Laszewski

Obamacare is impacting the small group insurance market in many of the same ways as the individual health insurance market. While employers with less than 50 workers don’t have to provide coverage, if they do they are required to comply with the same essential benefit mandates, age rating changes, and pre-existing condition reforms the individual market faces.

That means essentially all small group policies cannot continue as they are––they have to be discontinued.

What makes things a bit easier, if not any less expensive, is that small employers typically have health insurance brokers to run interference for them and help them through this change where individual consumers often get that dreaded cancellation letter telling them they will not have health insurance after a certain date if they do not act quickly in what is a confusing marketplace in the best of times.

The first small group renewals are now occurring––the January 1 renewals that typically have to be delivered during the month of November under state law.

Many employers are facing significant changes in order to comply with Obamacare and therefore price increases. One Maryland broker I spoke to this week has 90 small group accounts and he reports his smallest increase was 15%, his largest was 69%, and most are in the 30% – 40% range.

(By comparison, Mercer just announced the average large employer health care cost increase for 2014 will be 5.2%, meaning small groups could have reasonably expected an increase under 10% without Obamacare.) The biggest rate increases are generally going to those employers with the youngest groups the most impacted by the new “age compression” rules.

Does this mean these small employers’ coverage has been outright cancelled and they will now send their workers to the exchanges, as I have heard some commentators argue?

No, at least not anytime soon.

But that does not mean that lots of these small employers aren’t angry and confused.

What are these small employers doing?

Continue reading…

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