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Better But Nowhere Near Good Enough

• 8

By Robert Laszewski

I can provide you with an Obamacare federal exchange rollout update from two decidedly different perspectives:

  1. The website is working much better with enrollment increasing at least three-fold over just a few weeks ago with backroom error rates considerably improved; or
  2. The enrollment, to give you a general sense of what’s happening, for a health plan that might have to sign-up 100,000 people in order to get their share of the 7 million Obama administration’s national enrollment objective, has grown from perhaps 10-15 enrollments a day a few weeks ago to 40-50 a day now. If this new higher trend continues, such a plan would sign up only another 12,000 people toward the 100,000 objective by March 31. Backroom error rates being committed by Healthcare.gov, when enrollment data are transmitted to the health plans, are still far too high to transition to high volume processing without serious customer service issues.

So, pick your perspective. Most importantly, Healthcare.gov is not ready for what could come in just two weeks when, between December 1 and December 15, everyone expects massive pressure on the federal Obamacare enrollment and administration site so people can get coverage by January 1.

My independent survey of health plans also matches comments by CMS Deputy Chief Information Officer Henry Chao today at a House hearing that 30% to 40% of the IT systems needed to support Obamacare still must be built. He also said that, “We [CMS] still need to build the payments systems to make the [subsidy] payments [to the health plans].”

I have been hearing reports from plans that CMS has said that the enrollee subsidy information was going to be mailed to the plans but I frankly didn’t believe it. Chao went on to say that other backroom functions, including accounting systems, were not complete.

That would be like a bank starting business and attracting customers without finishing their ability to send their customers’ monthly statements.

Chao’s comments just underscore the risk for considerable backroom and therefore customer service issues when volume picks up.

Continue reading…

The Cholesterol Gulag

• 14

By Vik Khanna, Tom Emerick & Al Lewis

Last week, we were amongst the very first opinion leaders to speak out against the new cholesterol guidelines from the American Heart Association (AHA) and the American College of Cardiology (ACC).

Our error was not going far enough.

Monday’s New York Times carried a devastating portrait of the development of the guidelines, leaving readers with the unmistakable impression that this absurd attempt to make people into patients was not just poor policy it was a hubristic, avoidable policy folly, sort of like the bridge to nowhere and federal housing policy pre-2008.

Trust is an interesting thing; once broken it almost resists reconstruction.  Public trust in the AHA and ACC is crumbling as we write and deservedly so, as what should have been clear becomes more confusing and conflicted by the minute.

Instead of giving generally healthy middle aged American adults (like the three of us) the safe haven of a cardiovascular disease (CVD) prevention framework that is understandable, sensible and actionable, we got a cholesterol gulag.  Only here in the land of the free, it’s not a government gulag imprisoning the political opposition.

No, in a phenomenon unique to the US, it’s a health gulag intended to take people who need advice, support, and guidance and give them a pill, which is the first step in an intentional ensnarement in the medical care system.  It’s the Hospital California…on steroids, and you can’t even checkout because that would be against this addled medical advice.

To clarify: we have zero objection to providing statins, especially low-cost generic ones, to people under age 75 with current CVD, diabetes, or extremely high cholesterol levels.  The drugs may very well save their lives.

Our beef is with the cockamamie reduction in the ‘risk-to-treat’ threshold from 10% risk of heart attack or stroke in the next 10 years to 7.5% for people with none of the above noted problems.

Continue reading…

Think You’re Young and Invincible? You’re Young, Yes. Invincible? Maybe Not.

• 4

By Kathleen Reardon

Life was getting underway the day I found a suspicious lump. My first book had just been published and was being received well in my field. I was traveling and speaking about a new research project. The phone kept ringing and there was little time to think.

I figured that was the reason why my weight was falling. It was one of those good side benefits of a busy schedule. Why worry about a pea-sized lump? Lots of women have those and they turn out to be nothing. Coincidentally, that was exactly what my gynecologist said it was: nothing but a cyst.

Two more visits to that doctor resulted in him telling me that, at my age and with my family history, there was nothing to worry about and I should get on with life. He refused my request for a mammogram, suggesting that I should relax. I gave relaxation a try until a friend told me, “You look bad. If you don’t go see your GP for another opinion, I’m not going to talk to you.” There were dark lines under my eyes and I was becoming tired and downright skinny. I took her advice. It was cancer.

When I read about young people declining to sign up for health insurance, I remember back to that time. Sure, it’s great to be young. One of the best things is thinking you have a long time before you need to worry about your body giving you major problems. And isn’t life a gamble anyway?

I’m sure many young people reason this way and to some extent they’re right. Having spent a significant part of my career studying how people reason about health, it’s no surprise to me that weighing the odds causes a good many of us to take risks.

Yet, there is no such thing as a “young invincible,” the term currently bandied about to describe adults under the age of 35.

It’s not their fault if the system is unresponsive when they attempt to learn their insurance options. But it is their responsibility, to themselves and their families, to make sure that if something does go wrong — as it often does — their insurance will afford them the care that could save their lives.

Continue reading…

And Yes, The Affordable Care Act Really Does Make Care More Affordable. Here’s One Example ….

• 59

By Brian Klepper

Recently I was asked to intervene on behalf of a patient who, trapped by circumstance, was paying off an enormous bill for a lithotripsy procedure. What I uncovered wasn’t news, but it drove home how egregious the current system can be, why it so badly needs to be fixed, and how the Affordable Care Act (ACA) helps move us in the right direction.

The patient had health insurance through her husband’s job. But it was cancelled just after the hospital validated it, because the employer failed to pay the premium. The procedure was performed, and the patient was charged as “self-pay.”

If Medicare had been the payor in this case, the hospital’s total reimbursement would have been a little less than $2,000. But the lithotripsy and associated costs were billed at $33,160, or just under 17 times the Medicare rate. After the patient applied for financial assistance, a 30% contractual adjustment was applied, reducing her bill to just under 12 times the Medicare rate.

If the health system had asked her to pay 190 percent of Medicare – typically the upper end of commercial insurance rates – her bill would have been about $3,800. By the time I was contacted, the patient and her husband – responsible people trying to make good on their debt – had already paid the health system $5,700 or 285 percent of Medicare. The hospital insisted they owed an additional $16,000.

I laid this out in a letter to the CEO and, probably because he wanted to avoid a detailed description of this unpleasantness in the local paper, he relented, zeroing out the patient’s balance. No hospital executive wants to be publicly profiled as a financial predator.

But while that resolved that patient’s problem, it did nothing to change the broader practice. Most US health systems, both for-profit and not-for-profit, exploit self-pay patients in this way. Worse, not-for-profit health systems legally pillage their communities’ most financially vulnerable patients while getting millions of dollars in tax breaks each year for providing charity care.

Aggressive collections procedures, including  home liens, are widespread.
Some states have strictly limited what hospitals can charge low income patients. In California, uninsured patients with incomes below 350 percent of the federal poverty level (FPL) – $82,425 in 2013 for a family of 4 – can be charged no more than Medicare rates. In New Jersey, patients within 500 percent of the FPL cannot be charged more than 115 percent of Medicare.

Section 9007 of the ACA took effect last year and prohibits excessive pricing for self-pay patients, and would revoke a charitable hospital’s tax-exempt status if it charges them more than it charges for insured patients. The language is ambiguous, conceivably allowing health systems to circumvent the law’s intent. But the spirit is clear. To keep their not-for-profit tax status and perks, health systems must stop taking advantage of self-pay patients.

Continue reading…

The Real Fix? The Exchanges Aren’t Working. Here’s Why …

• 6

By David Dranove & Craig Garthwaite

Last week President Obama announced that he will try to keep his oft repeated promise to Americans in the individual market that they can keep their plans if they like them … for a year. The media have done an excellent job explaining why President Obama’s temporary patch to the ACA may endanger its existence; in the process the American public has learned more than it ever wanted to about adverse selection, cream skimming, and most importantly crass politics.

Though the full costs of adverse selection will be muted in the first year by risk corridors and reinsurance, it is clear that the failing website, the bad press, and the recently announced delay are placing maximal stress on even those backup provisions of the bill.

Even if the ACA survives this additional insult against the economics that support its very existence, we have witnessed yet another missed opportunity for positive reform to President Obama’s signature legislative achievement. And this time we can’t just blame intransigent tea-party Republicans and their quixotic efforts at repeal; here the buck stops at 1600 Pennsylvania Ave, NW.

While many of the plans that are affected by the President’s temporary patch might actually be plans that don’t qualify as “insurance” (i.e. they have low lifetime caps on expenditures or don’t cover hospital services), numerous others actually offer quite good coverage that just don’t meet the exceptionally high standards of the newly developed minimum essential health benefit (EHB).

In many ways, the first dollar coverage for preventive care and the wide ranging number of services covered by the ACA aren’t truly insurance either. Instead, these features amount to a very generous pre-payment plan for medical services supported by the United States treasury.

These elements of the EHB are too costly and unnecessary. Perhaps even more concerning, they are just the ante. As time goes on, vested interests for everything not included in the EHB will work tirelessly to insure that their favorite benefits are included. If you want evidence of this eventuality, you need look no further than the remarkably long and growing list of benefits mandated by most states.

Keep in mind that as the EHB grows more generous the premiums and subsidies on the exchanges will also grow. And we know who will pay their “fair share” of those increases.

Continue reading…

Addressing Unapproved Meningitis Vaccine at Princeton

• 4

By ARTHUR CAPLAN

Emergency doses of a meningitis vaccine not approved for use in the U.S. are likely to be on the way to Princeton University to halt a meningitis outbreak that has already sickened seven students. There are approved meningitis vaccines available, but they do not protect against Meningitis B—a strain not covered by the shots given in the U.S. and not a strain prevalent here.

Government health officials said Friday they have agreed to import Bexsero, a vaccine licensed only in Europe and Australia that does protect against meningitis B.  And that decision seems entirely reasonable given the threat that this nasty strain of meningitis poses.

That said, the question arises — what should those getting the vaccine be told?  Are they being offered a proven vaccine, an experimental vaccine, a vaccine believed to be the best choice given the threat of an epidemic or something else?  Can a student, campus worker or faculty member refuse the vaccination and stay in school or in a dorm?  Should those who have visited the campus recently be tracked down and offered the vaccine?  If people do refuse should they identify themselves in anyway as unvaccinated and to whom?

In general when using a drug or device that has not been approved by the FDA or other federal advisory agencies those who are offered the vaccine should be treated more as research subjects than patients.  They should be told all the facts about the vaccine, why it has not been approved in the U.S. and about the all too real threat that meningitis poses.  They should be given the opportunity to ask questions.  There is a duty to try and monitor those who get the vaccine or a representative sample of such persons, to watch for both efficacy and safety.  Vaccine refusal might be accepted, herd immunity could help in this regard, but university officials will need a policy concerning refusers and where they ought to go to study, live and work until the potential epidemic subsides.

Using a vaccine very likely to be safe and effective to stave off an outbreak of a nasty disease makes good moral sense.  However, it is important to treat emergency use as such and to do what can be done to inform subjects, track the results in those who are vaccinated and to find a path for those who will not accept vaccination.

Arthur Caplan, Ph.D. is head of the Division of Bioethics at New York University Langone Medical Center. This post originally appeared in bioethics.net blog.

New York State Plans Say “No Thanks” to Obama Fix

By THCB NEWS

This is clearly going to get complicated.

Next example: New York Health insurers say they probably won’t be taking up President Obama on his invitation to extend health plans cancelled earlier because they do not comply with the Affordable Care Act’s requirements.

“Just trying to go back and recreate a product that you’ve eliminated is not something that plans are looking forward to with great enjoyment,” Leslie Moran, vice president of the New York Health Plan Association said.

Besides, nobody is really sure New Yorkers want their old plans back anyway.

Premium increases on New York plans have been among the most modest in the country, largely because the New York individual insurance market was tightly regulated (translation = non-competitive) long before the Affordable Care Act came long.  Many New Yorkers have actually seen significant decreases in their monthly bills.

That’s one reason sales have been humming – well, pretty decent, anyway – on the New York exchange …

According to HHS, the state exchange enrolled 18,000 people in the month of October.

Worldone+Sermo’s next steps

• 3

By Matthew Holt

Worldone+Sermo is the combination created last year of physician research company Worldone Interactive and the physician community Sermo. Sermo was an early Health 2.0 favorite that somewhat lost its way with both its early business model and a dive into politics, but behind it was an interesting experiment in clinical crowdsourcing.

Peter Kirk is the CEO of the combined business and I spoke to him in advance of his appearance at Health 2.0 Europe today in London. What’s clear is that Sermo is both poised to expand internationally and going to grow as a serious platform for clinical exchanges among professionals Watch the interview above to learn much more.

And one charity Sermo is supporting, called Floating Doctors, is showing really innovative use of the platform to help patients in very remote regions get expert diagnoses. The second video is well worth watching and gives a great example of the iConsult product. And if you are in London today, Peter will tell you more!

 

Why Can’t I Change My Plan?

• 19

By THCBist

A THCB reader writes in with a question and a pretty disruptive suggestion. @NorCal Exchange writes:

“I’m a small business owner. I’m also a card-carrying Democrat. Frankly, I’m pretty pissed off about the way things have gone with this roll-out so far.  This was our one chance to get health reform right. And from what I can tell, we’ve totally screwed it up. Here’s one more thing a lot of the media coverage is missing. Even though THCB readers understand how open enrollment works, I’m guessing a lot of ordinary Americans don’t realize that under the new rules once they’ve applied for coverage they’re basically stuck with what they’ve got until the next enrollment period. This was a pretty big change in the first place. With all of this insanity, I’m guessing people are probably not reading the fine print and don’t know they’re locked in.

My prediction: there are going to be a lot of really unhappy people in the early part of 2014, when people realize what they’ve gotten themselves into. Why not allow people to change their plans? If you want an Amazon.com for healthcare, make the market for health insurance the same way as the market for anything else. If people decide to upgrade their coverage let them. If they get pissed at UnitedHealth’s customer service, let them cancel their policy and switch to AETNA or CIGNA. If I’m an idiot and don’t want preventative coverage let me build my own plan. If I’m worried that my daughter might get cancer let me add the Mayo clinic to my network. If my kid plays sports, let me add better ortho coverage. Yeah. Yeah. I know. This will turn the traditional underwriting model upside down. And a couple of health plans may even go out of business. But so what? My business may end up going out of business.  These guys are smart. They’ll figure out twenty new ways to make money and they’ll end up thanking us for disrupting their precious monopoly …”

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