New estimates from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that 23 percent of 19-to-64-year-old adults who were insured all year—or 31 million people—had such high out-of-pocket costs or deductibles relative to their incomes that they were underinsured. These estimates are statistically unchanged from 2010 and 2012, but nearly double those found in 2003 when the measure was first introduced in the survey. The share of continuously insured adults with high deductibles has tripled, rising from 3 percent in 2003 to 11 percent in 2014. Half (51%) of underinsured adults reported problems with medical bills or debt and more than two of five (44%) reported not getting needed care because of cost. Among adults who were paying off medical bills, half of underinsured adults and 41 percent of privately insured adults with high deductibles had debt loads of $4,000 or more.
BACKGROUND
The Affordable Care Act has transformed the health insurance options available to Americans who lack health benefits through a job. Numerous surveys have indicated that the law’s coverage expansions and protections have reduced the number of uninsured adults by as many as 17 million people.1
But Congress intended the Affordable Care Act to do more than expand access to insurance; it intended for the new coverage to allow people to get needed health care at an affordable cost. Accordingly, for marketplace plans, the law includes requirements like an essential health benefit package, cost-sharing subsidies for lower-income families, and out-of-pocket cost limits.2 For people covered by Medicaid, there is little or no cost-sharing in most states.
But most Americans—more than 150 million people—get their health insurance through employers.3 Prior to the Affordable Care Act, employer coverage was generally far more comprehensive than individual market coverage.4 However, premium cost pressures over the past decade have led companies to share increasing amounts of their health costs with workers, particularly in the form of higher deductibles.5
In this issue brief, we use a measure of “underinsurance” from the Commonwealth Fund’s Biennial Health Insurance Survey to examine trends from 2003 to 2014, focusing on how well health insurance protects people from medical costs. Adults in the survey are defined as underinsured if they had health insurance continuously for the proceeding 12 months but still had out-of-pocket costs or deductibles that were high relative to their incomes (see Box #1). The survey was fielded between July and December 2014. This means that we could not separately assess the effects of the Affordable Care Act on underinsurance because people who were insured all year in the survey had insurance that began before the law’s major coverage expansions and reforms went into effect. People who had new marketplace or Medicaid coverage under the Affordable Care Act would not have had that coverage for a full 12 months, as it would have begun in January 2014 at the earliest. Similarly, people with individual market coverage who were insured all year would have spent all or part of the period in plans that did not yet reflect the consumer protections in the law.6
Health care that costs more than it needs to is not just an annoyance; it’s a big factor in income inequality in the United States. The financial, physical and emotional burden of disease are major drivers of poverty. At the same time, the high cost of health care even after the Affordable Care Act means that many people don’t access it when they need it, and this in turn deprives large swathes of the population of their true economic potential as entrepreneurs, workers and consumers. People who are burdened by disease and mental illness don’t start businesses; don’t show up for work; and don’t spend as much money on cars, smartphones and cool apartments. Unnecessary sickness is a burden to the whole economy.
How did we get this way? What was the mechanism that differentiated U.S. health care from all other advanced countries? The usual suspects (such as “We have the most sophisticated research and teaching hospitals,” or “It’s the for-profit health insurers” or “Doctors make too much”) all fail when we compare the United States with other sophisticated national systems such as those in Germany and France. Other countries have all of these factors in varying amounts — private health insurers, world-class research, well-paid physicians — and cost a lot, but still spend a far smaller chunk of their economy on health care. Blame has been leveled in every direction, but in reality no single part of health care has been the driver. The whole system has become drastically more expensive over the last three decades.
What’s the Mechanism?
Since the difference between the United States and other countries is so large and obvious, there should be some way we can look at health care spending that would make that mechanism jump out at us. And there is a way.
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That first big leap is between 1982 and 1983. What was different in 1983 that was not there in 1982? DRGs, diagnosis-related groups — the first attempt by the government to control health care costs by attaching a code to each item, each type of case, each test or procedure, and assigning a price it would pay in each of the hundreds of markets across the country. The rises continue across subsequent years as versions of this code-based reimbursement system expand it from Medicare and Medicaid to private payers, from inpatient to ambulatory care, from hospitals to physician groups and clinics, to devices and supplies, eventually becoming the default system for paying for nearly all of U.S. health care: code-driven fee-for-service reimbursements.
Cost Control Drives Costs Up?
How can a cost control scheme drive costs up? In a number of ways: In an attempt to control the costs of the system, the DRG rubric controlled the costs of units, from individual items like an aspirin or an arm sling to the most comprehensive items such as an operation or procedure. The system did not pay for an entire clinical case across the continuum of care from diagnosis through rehab; or for an entire patient per year on a capitated basis, which would capture the economic advantages of prevention; or for an entire population. While it is more cost-effective (as well as better medicine) to provide a diabetes patient with medical management, in-home nursing visits and nutritional counseling rather than, say, waiting until the patient needs an amputation, the coding system actually punished that efficiency and effectiveness. Under this system, we got paid for our inefficiencies, and even for our mistakes: Do-overs would often drop far more to the bottom line than the original procedure did.
The system punished, rather than rewarded, spending more time with patients, trying to help patients before their problems became acute, or maintaining a long-term, trusted relationship with patients. Under a code-driven fee-for-service system, getting serious about prevention and population health management would be a broad road to bankruptcy.
If extra items were deemed necessary (an extra test or scan, say), there were codes for that, and reimbursements awaiting. In so doing, the system rewarded doing more (“volume”) rather than whatever would be the best, most appropriate, most efficient treatment path (“value”). It provided a written, detailed catalog of reimbursements which rewarded diagnoses of greater complexity, rewarded new techniques and technologies with new and usually higher reimbursements, and especially rewarded systems that invested in a greater capability to navigate the coding system. At the same time, the reimbursements were constantly open to pressure from the industry. Each part of the industry, each region, each specialty, each part of the device industry, became fiercely focused on keeping those reimbursements up, and getting new codes for more costly procedures.
The business and strategic side of health care became a matter of making money by farming the coding system. Do more of what gets better reimbursement, less of what does not. Make sure every item gets a code and gets charged for. The codes became a manual for success, a handbook for empire.
The Smoking Gun
The smoking gun is right there in the chart, at the big split between the trajectories of the United States and other countries. And today, at this moment, the code-based fee-for-service payment system is still by far the basis of the majority of all revenue streams across health care.
The unifying factor between multiple new strategies unfolding in health care right now, including patient-centered medical homes, pay for performance, bundled prices, reference prices, accountable care organizations, direct pay primary care and others, is to find some way around the strict code-based fee-for-service system, either by avoiding it entirely or by adding epicycles and feedback loops to it to counter its most deleterious effects.
There is no perfect way to pay for health care. All payment methods have their drawbacks and unintended consequences. But the code-based fee-for-service system got us here, and any path out of the cost mess we are in has to get us off that escalator one way or another.
UCLA health care policy analysis finds four key problem areas for Latinos under Affordable Care Act
Latinos are the largest ethnic minority group in the United States, and it’s expected that by 2050 they will comprise almost 30 percent of the U.S. population. Yet they are also the most underserved by health care and health insurance providers.
Latinos’ low rates of insurance coverage and poor access to health care strongly suggest a need for better outreach by health care providers and an improvement in insurance coverage. Although the implementation of the Affordable Care Act of 2010 seems to have helped (approximately 25 percent of those eligible for coverage under the ACA are Latino), public health experts expect that, even with the ACA, Latinos will continue to have problems accessing high-quality health care.
Alex Ortega, a professor of public health at the UCLA Fielding School of Public Health, and colleagues conducted an extensive review of published scientific research on Latino health care. Their analysis, published in the March issue of the Annual Review of Public Health, identifies four problem areas related to health care delivery to Latinos under ACA:
The consequences of not covering undocumented residents.
The growth of the Latino population in states that are not participating in the ACA’s Medicaid expansion program.
The heavier demand on public and private health care systems serving newly insured Latinos.
The need to increase the number of Latino physicians and non-physician health care providers to address language and cultural barriers.
“As the Latino population continues to grow, it should be a national health policy priority to improve their access to care and determine the best way to deliver high-quality care to this population at the local, state and national levels,” Ortega said. “Resolving these four key issues would be an important first step.”
Insurance for the undocumented
Whether and how to provide insurance for undocumented residents is, at best, a complicated decision, said Ortega, who is also the director of the UCLA Center for Population Health and Health Disparities.
For one thing, the ACA explicitly excludes the estimated 12 million undocumented people in the U.S. from benefiting from either the state insurance exchanges established by the ACA or the ACA’s expansion of Medicaid. That rule could create a number of problems for local health care and public health systems.
For example, federal law dictates that anyone can receive treatment at emergency rooms regardless of their citizenship status, so the ACA’s exclusion of undocumented immigrants has discouraged them from using primary care providers and instead driven them to visit emergency departments. This is more costly for users and taxpayers, and it results in higher premiums for those who are insured.
In addition, previous research has shown that undocumented people often delay seeking care for medical problems.
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As the ACA is implemented and more people become insured for the first time, local community clinics will be critical for delivering primary care to those who remain uninsured.
“These services may become increasingly politically tenuous as undocumented populations account for higher proportions of clinic users over time,” he said. “So it remains unclear how these clinics will continue to provide care for them.”
In recent weeks, the market has reacted to a few noteworthy headlines, all involved with or touching upon value-based discretionary actions, and many with the not-so-hidden question: What’s In It for Me or WIIFM?
CMS announced that by 2016 30% of fees in health care should be paid for through a value-based system, moving away from fee-for-service.
ACO results have shown ambivalent outcomes.
Outcomes-based contracts have permeated the Hepatitis C cost-nado (that’s a cost sharknado, the kind that fiercely defies cost controls and takes over all noise about payment reform and patient preferences).
Reference-based pricing is a good/bad troublemaker in the middle of the value-based travails.
The latest rampages have appeared on two national and highly-regarded blogs: The Health Care Blog [Value-Based Reform] and The Health Affairs Blog [Go Slow on Reference Pricing].
As one of the loudest proponents on value-based designs, I lift the curtain again to show the thinking behind the movement from fee for service to value-based designs. All of these items above discuss the message of payment reform, or system alignment, but they are intensely linked to the patient-consumer ability to make the right choices, choose the right sites for care, and pay the right amount for services rendered to achieve health security.
WSB-Atlanta recently explored what happens when hospitals buy physician practices, which has been happening all over the Atlanta area.
Prices for patients go up.
The same physicians – in the same offices, with the same treatments – start charging more.
“Everything is exactly the same,” said cancer patient Mike Rosenberg.
Except the bill.
Sometimes it’s an “outpatient facility fee.” And sometimes it’s a “treatment room fee.”
And it’s a lot of money – sometimes thousands of dollars, not covered by insurance.
And even patients who are savvy enough to know about these fees before they get the bill have a lot of trouble finding out about them, as Erica Byfield made clear in her strong 3-minute report.
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It’s not unique to Atlanta. She quotes a University of California, Berkeley, studythat found that patients generally pay 10 percent more at hospital-owned practices.
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The ACA does include incentives for “vertical integration,” or having doctors and physicians part of one organization. But it’s not supposed to raise costs. It’s supposed to bring them down by improving efficiency, creating economies and encouraging care coordination. (Some of the fee problems actually stem from Medicare billing practices, not specifically the ACA.)
A predictable irony of the never-ending Affordable Care Act (ACA) debate is that the one provision that the Republicans should be attacking — free “checkups” for everyone — is one of the few provisions they aren’t attacking. Why should they attack them? Simple — checkups, on balance, are worthless. Why provide a 100 percent subsidy for a worthless good? Where is the GOP when you need it?
How worthless are checkups? Dr. Ezekiel Emanuel — one of the architects of the ACA and its “free” checkup centerpiece — recently recommended not getting them. As if “free” is not cheap enough, the ACA also pushes ubiquitous corporate wellness programs, which often pay employees to get checkups — or fine them if they don’t. This policy establishes a de facto negative price for millions of workers, making checkups the only worthless service on earth that one could get paid to utilize.
Those economics of a “negative price” trump Dr. Emanuel’s advice, and have made preventive care the fastest-growing component of employer health spending. Though hard statistics on checkups themselves are elusive, Dr. Emanuel estimates about 45-millon adult checkups are conducted each year, the equivalent of roughly 8 percent of America’s PCPs doing nothing but checkups, a curious use of their time when experts say the country could soon face a shortage of PCPs.
Shortage or not, subsidies and incentives might make economic sense if checkups improved health. However, when generally healthy adults go to the doctor for no reason, just the opposite is true: the Journal of the American Medical Association (JAMA) supports Dr. Emanuel assertion that annual checkups for asymptomatic adults are at best worthless, saying that additional checkups are “not associated with lower rates of mortality” but “may be associated with more diagnoses and more drug treatment.”
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The solution to this orgy of overscreening and overdoctoring is remarkably simple: remove the ACA provision that makes annual checkups automatically immune from deductibles and copays; if they are going to be free at all, it should only be every few years. The proposal could still allow employers to override this provision — and even to attach money (incentives and penalties) to checkups — if they are willing to summarize the above-cited clinical findings for their employees.
If the only way they can continue the subsidy is by summarizing the literature, corporate human resources departments would predictably and immediately curtail this expensive corporate medical campaign. That would free up PCP time to work with patients who actually need medical care, while reducing counterproductive and costly healthcare utilization by those who do not.
“I think the Affordable Care Act is actually doing quite well,” says Senior Fellow Alice Rivlin in this podcast. Rivlin, the Leonard D. Schaeffer Chair in Health Policy Studies and director of the Engelberg Center for Health Care Reform at Brookings, cited the expansion of medical insurance coverage, declining cost growth, and other positive factors for the ACA. She also reflects on continued political opposition to the law, the impending King v. Burwell Supreme Court case, and what it was like to stand up a new federal agency, the Congressional Budget Office, in 1975.
[This is a screenshot, was unable to upload via an application similar to YouTube]
[This is a screenshot, was unable to upload via an application similar to YouTube]
Also in the podcast, Senior Fellow David Wessel, director of the Hutchins Center on Fiscal and Monetary Policy, offers his regular “Wessel’s Economic Update.”
Eliminating discrimination on the basis of preexisting conditions is one of the central features of the Affordable Care Act (ACA). Before the legislation was passed, insurers in the nongroup market regularly charged high premiums to people with chronic conditions or denied them coverage entirely. To address these problems, the ACA instituted age-adjusted community rating for premiums and mandated that plans insure all comers. In combination with premium subsidies and the Medicaid expansion, these policies have resulted in insurance coverage for an estimated 10 million previously uninsured people in 2014.1
There is evidence, however, that insurers are resorting to other tactics to dissuade high-cost patients from enrolling. A formal complaint submitted to the Department of Health and Human Services (HHS) in May 2014 contended that Florida insurers offering plans through the new federal marketplace (exchange) had structured their drug formularies to discourage people with human immunodeficiency virus (HIV) infection from selecting their plans. These insurers categorized all HIV drugs, including generics, in the tier with the highest cost sharing.2
Insurers have historically used tiered formularies to encourage enrollees to select generic or preferred brand-name drugs instead of higher-cost alternatives. But if plans place all HIV drugs in the highest cost-sharing tier, enrollees with HIV will incur high costs regardless of which drugs they take. This effect suggests that the goal of this approach — which we call “adverse tiering” — is not to influence enrollees’ drug utilization but rather to deter certain people from enrolling in the first place.
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We found evidence of adverse tiering in 12 of the 48 plans — 7 of the 24 plans in the states with insurers listed in the HHS complaint and 5 of the 24 plans in the other six states (see theSupplementary Appendix for sample formularies). The differences in out-of-pocket HIV drug costs between adverse-tiering plans (ATPs) and other plans were stark (seegraphAverage HIV-Related Costs for Adverse-Tiering Plans (ATPs) versus Other Plans.). ATP enrollees had an average annual cost per drug of more than triple that of enrollees in non-ATPs ($4,892 vs. $1,615), with a nearly $2,000 difference even for generic drugs. Fifty percent of ATPs had a drug-specific deductible, as compared with only 19% of other plans. Even after factoring in the lower premiums in ATPs and the ACA’s cap on out-of-pocket spending, we estimate that a person with HIV would pay more than $3,000 for treatment annually in an ATP than in another plan.
Our findings suggest that many insurers may be using benefit design to dissuade sicker people from choosing their plans. A recent analysis of insurance coverage for several other high-cost chronic conditions such as mental illness, cancer, diabetes, and rheumatoid arthritis showed similar evidence of adverse tiering, with 52% of marketplace plans requiring at least 30% coinsurance for all covered drugs in at least one class.3 Thus, this phenomenon is apparently not limited to just a few plans or conditions.
Adverse tiering is problematic for two reasons. First, it puts substantial and potentially unexpected financial strain on people with chronic conditions. These enrollees may select an ATP for its lower premium, only to end up paying extremely high out-of-pocket drug costs. These costs may be difficult to anticipate, since calculating them would require knowing an insurer’s negotiated drug prices — information that is not publicly available for most plans.
Second, these tiering practices will most likely lead to adverse selection over time, with sicker people clustering in plans that don’t use adverse tiering for their medical conditions.
New results from the Commonwealth Fund Biennial Health Insurance Survey, 2014, indicate that the Affordable Care Act’s subsidized insurance options and consumer protections reduced the number of uninsured working-age adults from an estimated 37 million people, or 20 percent of the population, in 2010 to 29 million, or 16 percent, by the second half of 2014. Conducted from July to December 2014, for the first time since it began in 2001, the survey finds declines in the number of people who report cost-related access problems and medical-related financial difficulties. The number of adults who did not get needed health care because of cost declined from 80 million people, or 43 percent, in 2012 to 66 million, or 36 percent, in 2014. The number of adults who reported problems paying their medical bills declined from an estimated 75 million people in 2012 to 64 million people in 2014. Read the brief.
Citation:
S. R. Collins, P. W. Rasmussen, M. M. Doty, and S. Beutel, The Rise in Health Care Coverage and Affordability Since Health Reform Took Effect, The Commonwealth Fund, January 2015.
From the post at Full Text Reports
Source: Journal of Medical Internet Research
Background:
Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health.
Objective:
The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics.
Methods:
We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews.
Results:
Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts.
Conclusions:
Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services.
From the 28 January 2015 post at Engineering Evil – Intel Portal for Weighted Data and Information
In some US health plans, HIV drugs cost nearly $3,000 more per year than in other plans. If left unchecked, this practice could partially undermine a central feature of the Affordable Care Act.
Harvard School of Public Health
Boston, MA — Some insurers offering health plans through the new federal marketplace may be using drug coverage decisions to discourage people with HIV from selecting their plans, according to a new study from Harvard T.H. Chan School of Public Health. The researchers found that these insurers are placing all HIV drugs in the highest cost-sharing category in their formularies (lists of the plans’ covered drugs and costs), which ends up costing people with HIV several thousands more dollars per year than those enrolled in other plans.
I’m sure a lot of you have Steven Brill’s “America’s Bitter Pill” on your bedside table by now – I’m not going to try to recap it here.
But I did want to share a few links to some of the more thoughtful (or provocative) articles and reviews, representing critics on both the left and right. I also wanted to draw your attention to another recent book providing a conservative perspective on health reform.
Here’s a Sunday New York Timesbook review by Zephyr Teachout.
And Peter Orszag (who was in the Obama administration when the bill was being written and appears in the book) at Bloomberg View writes about what he thinks Brill got wrong.
Ready or not, the Affordable Care Act (ACA) is once again heading to the Supreme Court. At stake is whether the law allows consumers purchasing insurance through the Federal portal to extend the same discounts that states provide. Eliminating the discount could gut the exchange’s value to federal consumers. In the meantime, it’s enrollment as usual for 2015. Share this this updated ACA enrollment guide from the IOM.
2. Defending Safety Net and Programs and Regulations
Medicare Private voucher program proposal. With a new GOP majority, I expect to revisit proposals to privatize Medicare. The American Public Health Association (APHA) is on record opposing such a policy move as undermining the foundation of Medicare’s guaranteed coverage. Brace yourselves for some ideological power-plays over health care access for seniors.
Access to Abortion Services. APHA supports Access to abortion and ensuring the availability of qualified practitioners. The access to safe and legal abortion services at the state level has narrowed rapidly across the majority of US states since 2013. Now, this sharply partisan issue is likely provoke both Congressional challenges and more states to seeking to restrict these services, especially for low-income women.
Environmental Protections. Expect attacks on environmental regulations and the Environmental Protection Agency (EPA). Republicans are candid that their goal is to end the EPA. Clean air standards and more may be threatened.
3. New Vaccines
Ebola Vaccine. Likely the most fast-tracked vaccine trials ever, I’m not the only one predicting that we’ll see an ebola vaccine in 2015. Together with infection control protocols established for the affected West African countries, this will hasten the end to what had seemed an intractable crisis—though we’re not likely to snuff out ebola completely within the year.
HPV Nonavalent Vaccine. Merck’s nine-valent HPV vaccine received FDA approval in 2014. It’s very likely that this will replace, or partially replace, their current quadrivalent (4-valent) version. The newer vaccine will increase the percentage of cancer-causing HPV types prevented from 70% to 90% and potentially prevent tens of thousands of cancers per year. It may only need 2 doses instead of the current 3. The Advisory Committee on Immunization Practices (ACIP) should make a recommendation in the first half of 2015 with rollout later in the year.
4. National Policy on Police Violence in Communities of Color
Of the many hidden gems in the Affordable Care Act, one of my favorites is Physician Compare. This website could end up being a game changer—holding doctors accountable for their care and giving consumers a new way to compare and choose doctors. Or it could end up a dud.
The outcome depends on how brave and resolute the Centers for Medicare and Medicaid Services (CMS) is over the next few years. That’s because the physician lobby has been less than thrilled with Physician Compare, and, for that matter, with every other effort to publically report measures of physician performance and quality.
I’d give CMS a C+ to date. Not bad considering it’s the tough task. The agency has been cautious and deliberate. But after the many problems with Hospital Compare, Nursing Home Compare, Home Health Compare, and Dialysis Facility Compare—not to mention the shadow of healthcare.gov’s initial rollout—that’s understandable. They want, I hope, to get this one right from the get-go. And competition from the private sector looms.
Congress mandated that CMS establish Physician Compare by Jan. 1, 2011 and that an initial content plan be submitted by Jan. 1, 2013. CMS met those deadlines, albeit with a rudimentary site that launched in late December 2010. The agency updated its plans in 2013 and 2014, even as it added more content and functionality to the site.
The law requires the site to have “information on physician performance that provides comparable information on quality and patient experience measures.” That’s to include measures collected under the Medicare Physician Quality Reporting System (PQRS), Medicare’s main quality reporting vehicle, and assessments of:
patient health outcomes and the functional status of patients
continuity and coordination of care and care transitions, including episodes of care and risk-adjusted resource use
the efficiency of care
patient experience and patient, caregiver, and family engagement
the safety, effectiveness, and timeliness of care
Notably, Congress set no deadline for the site to meet those specifications or be fully operational.
So what’s posted so far? The centerpiece of the site is a searchable directory of some 850,000 Medicare providers. That includes most of the practicing doctors in the U.S. with the exception of pediatricians and other physicians who don’t treat Medicare patients. This database predates the ACA and Physician Compare but its functionality, reliability and accuracy (a big complaint from physician groups) is being gradually enhanced.
Each doctor has his or her own profile page—a significant foundation that could accommodate quality and patient experience data in the future.
Consumers can also search three additional databases on the site. They identify doctors and other clinicians who participate in (a) PQRS; (b) the Electronic Prescribing Incentive Program; and (c) the electronic health record (EHR) incentive program (also called the meaningful-use program). About 350,000 physicians and other clinicians participate in the latter.
The bad news: these databases are separate and their content is not integrated. That makes searching for information on a particular group practice or individual doctor cumbersome and time consuming. And the databases aren’t user-friendly. On the plus side, for researchers and health administrators, the databases are downloadable.
It’s time to toss the whole business-as-usual model — for your own good and the good of your customers.
The emerging Default Model of health care — the “consumer-directed” insured fee-for-service model in which health plans compete to lower premiums by bargaining providers into narrow networks — not only does not work for health care’s customers, it cannot work. This is not because we are doing it wrong or being sloppy. By its very nature the Default Model must continually fail to bring our customers what they want and desperately need. Ultimately it cannot bring you, the providers, what you want and need.
Take a dive with me into the real-world game-theory mechanics of the health care economy, and you will see why. It’s time to rebuild the fundamental business models of health care.
The Default Model Health Care Game
It’s a little easier to find our way around an economic model by picturing it as a game and asking: “What defines winning for each player? What does each player need to do to win?”
Health plans: For health plans, winning means surviving, succeeding and growing as a business. But there are a couple of rule changes now. Health plans used to be able to stay more profitable by pushing down their medical loss ratio (MLR — the percentage of premiums actually paid out for medical care), by “rescinding” the plans of people who cost too much, and by refusing to cover anyone with pre-existing conditions.
Now they have to take everybody, can’t toss them out, and their MLR has to be at least 80 percent (or 85 percent for large customers). So their administrative expenses, advertising, executive salaries (and the profits and stock price of the for-profits) are all tied to a percentage of the actual costs of health care. Hmmm. If they were confronted with a way to make health care cost half as much, would they be interested? Would they make it a top priority? No. They have no incentive to actually drop the real costs of health care.
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Related articles
While I agree with the author of the above article, the selected related articles do include other viewpoints.
From the 20 January 2015 Penn Medicine press release
JAMA Viewpoint Characterizes Current Model for Treating Mentally Ill as “Ethically Unacceptable and Financially Costly”
PHILADELPHIA — As the United States population has doubled since 1955, the number of inpatient psychiatric beds in the United States has been cut by nearly 95 percent to just 45,000, a wholly inadequate equation when considering that there are currently 10 million U.S. residents with serious mental illness. A new viewpoint in JAMA,written by Dominic Sisti, PhD, Andrea Segal, MS, and Ezekiel Emanuel, MD, PhD, of the department of Medical Ethics and Health Policy in the Perelman School of Medicine at theUniversity of Pennsylvania, looks at the evolution away from inpatient psychiatric beds, evaluates the current system for housing and treating the mentally ill, and then suggests a modern approach to institutionalized mental health care as a solution.
English: Pilgrim Psychiatric Center (Photo credit: Wikipedia)
“For the past 60 years or more, social, political and economic forces coalesced to move severely mentally ill patients out of psychiatric hospitals,” write the authors. They say the civil rights movement propelled deinstitutionalization, reports of hospital abuse offended public consciousness, and new drugs gave patients independence. In addition, economics and federal policies accelerated the transformation because outpatient therapy and drug treatment were less expensive than inpatient care, and the federal legislation like the Community Mental Health Centers Act and Medicaid led to states closing or limiting the size of so-called institutions for mental diseases.
However, the authors write, “deinstitutionalization has really been transinstitutionalization.” Some patients with chronic psychiatric diseases were moved to nursing homes or hospitals. Others became homeless, utilizing hospital emergency departments for both care and housing. But “most disturbingly, U.S. jails and prisons have become the nation’s largest mental health care facilities. Half of all inmates have a mental illness or substance abuse disorder; 15 percent of state inmates are diagnosed with a psychotic disorder.” According to the authors, “this results in a vicious cycle whereby mentally ill patients move between crisis hospitalization, homelessness and incarceration.”
Instead, the authors suggest that a better option for the severely and chronically mentally ill, and the most “financially sensible and morally appropriate way forward includes a return to psychiatric asylums that are safe, modern and humane.” They argue that the term ‘aslyum’ should be understood in its original sense — a place of safety, sanctuary and healing.
“Asylums are a necessary, but not sufficient component of a reformed spectrum of psychiatric services,” write the authors. Reforms need to expand the role of these institutions to address a full range of integrated psychiatric treatment services — from providing care to patients who cannot live alone or are a danger to themselves and others, to providing care to patients with milder forms of mental illness who can thrive with high-quality outpatient care. These fully-integrated, patient-centered facilities do exist in the U.S. today, but more are needed to provide 21st century care to patients with chronic, serious mental illness.
WHY WE DID THIS STUDY
Medicare hospice care is intended to help terminally ill beneficiaries continue life with
minimal disruption and to support families and caregivers. Care may be provided in
various settings, including a private home or other places of residence, such as an assisted
living facility (ALF). Pursuant to the Patient Protection and Affordable Care Act, the
Centers for Medicare & Medicaid Services (CMS) must reform the hospice payment
system, collect data relevant to revising payments, and develop quality measures. This
report provides information to inform those decisions and is part of the Office of
Inspector General’s (OIG) larger body of work on hospice care. While the report focuses
on ALFs, many of the issues identified pertain to the hospice benefit more broadly.
HOW WE DID THIS STUDY
We based this study on an analysis of all Medicare hospice claims from 2007 through
2012. We used Certification and Survey Provider Enhanced Reports data and Healthcare
Cost Report Information System reports for information on hospice characteristics.
WHAT WE FOUND
Medicare payments for hospice care in ALFs more than doubled in 5 years, totaling
$2.1 billion in 2012. Hospices provided care much longer and received much higher
Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings.
Hospice beneficiaries in ALFs often had diagnoses that usually require less complex care.
Hospices typically provided fewer than 5 hours of visits and were paid about $1,100 per
week for each beneficiary receiving routine home care in ALFs. Also, for-profit hospices
received much higher Medicare payments per beneficiary than nonprofit hospices. This
report raises concerns about the financial incentives created by the current payment
system and the potential for hospices to target beneficiaries in ALFs because they may
offer the hospices the greatest financial gain. Together, the findings in this and previous
OIG reports show that payment reform and more accountability are needed to reduce
incentives for hospices to focus solely on certain types of diagnoses or settings.
WHAT WE RECOMMEND
We recommend that CMS, as part of its ongoing hospice reform efforts: (1) reform
payments to reduce the incentive for hospices to target beneficiaries with certain
diagnoses and those likely to have long stays, (2) target certain hospices for review, (3)
develop and adopt claims-based measures of quality, (4) make hospice data publicly
available for beneficiaries, and (5) provide additional information to hospices to educate
them about how they compare to their peers. CMS concurred with all five
recommendations.
From the 24 November 2014 Robert Woods Foundation report
Recent years have brought numerous efforts to educate and engage Americans in what “quality” health care is, how to find it and how they can get better value for their dollars. To better understand the latest trends, the Robert Wood Johnson Foundation funded the AP-NORC Center for Public Affairs Research at the University of Chicago to conduct three surveys through the summer and fall of 2014.
The surveys each individually examined how consumers and employers, as purchasers, perceive health care quality and how they use quality information and performance data on health plans and providers. Learn more about the research and access links to the full reports with accompanying materials.
A number of initiatives in recent years have aimed at engaging consumers in making informed health care decisions, including empowering patients and their caregivers with data on provider quality, performance, cost and value. The first in the series of surveys looks at the inroads these efforts have made.
Thirty-seven percent of respondents don’t believe that higher health care costs correlate with better quality care—but 48 percent think they do. The poll also found that more than two-thirds say finding a doctor or hospital that offers the highest quality at the lowest possible cost is important to them. The survey also showed getting Americans to find quality information and use it in their health care decisions remains a challenge, with only 11 percent of Americans reporting they have done so.
As more provisions of the Affordable Care Act (ACA) are implemented over the next decade, the government projects that approximately 12 million additional people younger than 65 will enter the private insurance market. The second in the series of surveys looks at consumer opinions on health care costs and coverage, and how it impacts their decision-making.
It shows that nearly a fifth of insured Americans report skipping a trip to the doctor when they’re sick or injured to save money, and only 36 percent are confident they can pay for a major, unexpected medical expense. Those enrolled in health plans with high deductibles are greatly impacted by the out-of-pocket cost of health care—they are concerned with the uncertainty of major expenses, skip necessary medical treatment, and experience real financial burden when obtaining health care.
As a group, employers represent the largest purchaser of care in the United States. Given this, it is critical that they demand good value for the money they spend, ensuring that the plans offered to employees be high quality. The third and final report in the series of surveys looks at the opinions of private sector employers, including small-, medium- and large-sized businesses.
It shows that American firms are hesitant to say they would pay more for higher quality care, and when it comes to measuring quality, 90 percent don’t know or don’t use independent quality information when deciding on what plans to offer employees. And while many employers are indeed providing wellness programs to benefit their employees’ health, relatively few are actively promoting those programs or offering incentives for participation.
From the 6 November 2014 item at HealthWorks Collective
What if we paid for patient recovery rather than just patient services?
What if we paid to treat patients rather than just conditions?
What if we paid to personalize care rather just population health quality measures?
While these questions may sound academic, there is a groundswell of innovative healthcare providers working on the answers. To realign the healthcare system to overall patient recovery and well-being, it will take physicians and other healthcare providers transforming the entire system. The good news is that this is quietly happening from within, with physicians, healthcare systems and health plans working together.
With little debate or fanfare outside the healthcare industry, Medicare quietly saved $372 million with their versions of the ACO. While some critics predict that ACOs will follow Health Maintenance Organizations (HMOs) demise in the 1990s, ACOs are different. Patients are assigned to ACOs and remain free to go to any provider. ACOs can’t limit care or require patients to see providers in their network. The ACO’s were still able deliver great results even with these two major challenges which they call “churn” (ACO assigned patient turnover) and “leakage” (patients going outside the provider network).
Bundled Payments are just getting started with up to 6,500 providers deciding soon whether to go live Jan 1, 2015 with Medicare’s Bundled Payment for Care Improvement (BPCI) pilot. Provider/Health Plan risk sharing arrangements are expanding rapidly, indicating they are delivering. This surge began when the Affordable Care Act (ACA) started requiring health plans to write rebate checks if they paid out less than 85% of their premiums in medical claims. This encouraged Health Plans to partner and reward providers for improvements in patient outcomes and cost. Health Plans leaders believe that the “blurring of the lines” between providers and health plans is just getting started.
The regional variations are more complicated. It’s not as simple as labor costs in New York being higher than those in Arkansas.
Competition is a big factor. The highest prices aren’t necessarily in a big city. Some of the highest rates are in rural areas with few health care providers and scant competition to drive prices down.
Narrow networks, where there are fewer doctors and hospitals, or at least fewer name-brand hospitals, are also a factor. Not all consumers want these – although some are willing to make that tradeoff to save money.
There also may be fewer insurers offering coverage in the exchanges in some areas. Even where competition is minimal, the medical loss ratio in the Affordable Care Act limits how much profit an insurer can make or at least limits how much of the premium people pay can be used for nonmedical purposes – including profit. They have to rebate the money if they don’t meet MLR.
Local health care history and how it has affected incentives and efficiency is a factor. For instance, Minnesota, which has some of the lowest premiums, has been working on delivery system, integrated care and managed care for years.
Also, regional oddities – such as a mountainous section of Colorado that has to medevac people by helicopter – can play a role in why one section of a state pays more than others.
Jordan Rau of Kaiser Health News has written about the cheapest and most expensive markets nationally. Katie Kerwin McCrimmon of Health News Colorado has written about the controversy in Colorado about why people in one community pay more than people in an adjacent community. (Here and here).
Any journalist who covers nursing homes should check out this month’s special supplement in The Gerontologist, the Gerontological Society of America’s journal. It focuses on the two-decade long effort to change nursing home culture and many of the articles and studies raise important questions about whether enough progress has been shown.
English: Nursing Home in Goldthorn Hill. This area of Wolverhampton has a cluster of nursing homes. (Photo credit: Wikipedia)
For example, this study finds that nursing homes that are considered culture change adopters show a nearly 15 percent decrease in health-related survey deficiency citations relative to comparable nonadopting homes. This study looks at what is meant by nursing home culture change – the nature and scope of interventions, measurement, adherence and outcomes. Harvard health policy expert David Grabowski and colleagues take a closer look at some of the key innovators in nursing home care and what it might mean for health policy – particularly in light of the Affordable Care Act’s directive to provide more home and community-based care. Other articles look at the THRIVE study, mouth care, workplace practices, Medicaid reimbursement, and more policy implications.
Any of these studies — or several taken together — can serve as a jumping off point for local coverage. Are there nursing homes in your community that are doing things differently? Have any instituted policies or processes that show improvements in care coordination, outcomes, quality, or other key measures? Are there homes that are resisting change? Why? Which one(s) best exemplify person-centered care? How do these changes affect the workforce?
Nursing Home Compare from CMS provides the data behind complaints, violations, quality, and cost, among other metrics. This article in ThePhiladelphia Inquirer is a great example of interweaving research with personal narrative. Another approach might be to look at trends in the city, state, or region. How are nursing homes marketing themselves to consumers? To referral sources? Have their business models changed?
Experts on all sides have been talking about culture change for more than a decade. And in 2008, a Commonwealth Fund report explored culture change in nursing homes. Has the time finally come, for real?
Your wellness vendor says you are: But are you really sick?
Don’t take our for it that these workplace wellness programs are a complete and utter waste of your time and blood and your employer’s money, and can even generate medical treatments you don’t need. Do the arithmetic yourself. (The next paragraph does contain a little math but on the bright side if you can follow it, you can probably continue to live independently for at least a few more years.)
Assume a vendor finger-stick test that you get at your company’s “health fair” is 96 percent accurate. Further assume that vendors are seeking silent disorders that on average have a 1 percent prevalence. Do you suppose your odds of a false positive in those circumstances are 4 percent? To use a technical clinical term, nope. Out of 100 employees, the single employee who is actually afflicted with this disorder should test positive. Unfortunately, 4 of the other 99 will also test positive even though they are fine…because a 96%-accurate test is also 4%-inaccurate. This means of the 5 people who test positive, only 1 has the disorder—a false positive rate of 80 percent!
And that’s just on one test. With that kind of accuracy, it’s odds-on that if you get all the tests with all the frequencies that a wellness vendor recommends, at least one lab value will eventually be outside a normal range…and potentially thrust you into the treatment trap. The key to surviving this testing jihad without being trapped is–as with just about everything else in wellness–to start with the assumption that the vendor is wrong. This is a pretty safe bet. How safe? I don’t even know you, but if you tell me the sky is green and a wellness vendor profiled in this book tells me the sky is blue, I’d at least go look out the window.
Those false-positives make overdiagnosis (finding and treating maladies that don’t exist) the rule, not the exception.
From the 27 January 2014 Brookings Institute post
The Affordable Care Act (aka “Obamacare”) was designed to expand health insurance coverage and hold down the cost of insurance, but it will also change incomes of many Americans according to initial projections of Brookings Senior Fellows Henry Aaron and Gary Burtless.
In their new, preliminary paper “Potential Effects of the Affordable Care Act on Income Inequality,” Aaron and Burtless find sizeable income gains in the bottom quarter of the income distribution offset by small losses spread across higher income groups. Their estimates are highly sensitive to the definition of income. They discussed their paper in a recent event, joined by three other economists in a panel discussion.
The Affordable Care Act (aka “Obamacare”) was designed to expand health insurance coverage and hold down the cost of insurance, but it will also change incomes of many Americans according to initial projections of Brookings Senior Fellows Henry Aaron and Gary Burtless.
In their new, preliminary paper “Potential Effects of the Affordable Care Act on Income Inequality,” Aaron and Burtless find sizeable income gains in the bottom quarter of the income distribution offset by small losses spread across higher income groups. Their estimates are highly sensitive to the definition of income. They discussed their paper in a recent event, joined by three other economists in a panel discussion.
Joseph Burns (@jburns18), a Massachusetts-based independent journalist, is AHCJ’s topic leader on health insurance. He welcomes questions and suggestions on insurance resources and tip sheets at joseph@healthjournalism.org.
Later this year, health plans will be under new mental health parity rules affecting how insurers should cover patients with mental health and substance abuse disorders.
These rules, governing the limits that health insurers can place on coverage for patients needing mental health and substance abuse care, will be important to consumers for several reasons. One reason involves what services health plans must provide when covering mental health benefits –keep in mind that health plans do not need to offer mental health care. But if they do, they need to cover inpatient and outpatient services, emergency room care and prescription drugs, Andrews reports. Also, the rules prohibit health insurers from setting limits on treatment that are more restrictive than the limits set on a plan’s medical-surgical coverage, she adds.
In addition, intermediate-level mental health services, such as residential treatment and intensive outpatient services for patients needing substance abuse treatment or mental health care, should be covered at the same level as the insurer covers residential and intensive outpatient services for medical-surgical patients, Andrews adds. Often patients needing mental health and substance abuse care require residential or intensive outpatient treatment.
The new parity rules also do not allow health insurers to charge higher co-payments, deductibles, or out-of-pocket maximums for mental health and substance abuse treatment without setting similar co-payment, deductibles, and out-of-pocket limits for medical-surgical coverage.
Editor’s Note: This post is the third in a periodic Health Affairs Blog series on palliative care, health policy, and health reform. The series features essays adapted from and drawing on an upcoming volume, Meeting the Needs of Older Adults with Serious Illness: Challenges and Opportunities in the Age of Health Care Reform, in which clinicians, researchers and policy leaders address 16 key areas where real-world policy options to improve access to quality palliative care could have a substantial role in improving value.
In the United States, value is the new health care imperative – improving quality while controlling costs. We spend nearly twice the rate of comparable nations, yet have poorer health outcomes. In 2010, President Obama signed the Patient Protection and Affordable Care Act (ACA), mandating a new emphasis on paying for value, not volume.
Our greatest opportunity to enhance value in US health care is to improve quality of care for older adults with serious illness – the group who uses the most health care services. Serious illness, in which patients are unlikely to recover, stabilize, or be cured, is life-altering for patients and family caregivers. It includes advanced, symptomatic stages of diseases such as congestive heart failure, chronic lung disease, cancer, kidney failure, and dementia. Serious illness may also refer to the cumulative consequences of multiple conditions progressing over time, causing functional decline or frailty.
We’ve made important progress in understanding high quality care for this population of patients. Researchers have asked patients with serious illness and their families how they define high quality care. Especially in serious illness, patients want control over treatment through shared decision-making. Even when there is no cure, most patients still want health care that helps them live longer – but only if they can also get help with function, physical comfort, and attention to family, emotional and spiritual needs.
We know what types of health care help patients and families cope with serious illness. A 2012 report to the Agency for Healthcare Research and Quality finds evidence for three types of care to improve health outcomes:
Expert pain and symptom treatment
Communication to engage patient preferences for treatment decisions
Interdisciplinary palliative care
We’ve developed quality measures to understand how often real-world care lives up to these ideals.
Add this to the scary but improbable things people are hearing could happen because of the new federal health-care law: After you die, the state could come after your house.
The concern arises from a long-standing but little-known aspect of Medicaid, the state-federal program that provides health coverage to millions of low-
income Americans. In certain cases, a state can recoup its medical costs by putting a claim on a deceased person’s assets.
…
after the Affordable Care Act made it mandatory for most people to carry health insurance, Oregon’s Medicaid office decided to change its approach because people scared about asset recovery were not signing up for coverage. New rules that took effect last year state that asset recovery now applies only to long-term care.
“We needed to take another look at heath insurance coverage from the point of view of it not being a public benefit that’s voluntary,” Mohr Peterson said.
Other states have taken a much more lax approach to asset recovery in the past, hesitant to target poor people whose only valuable asset might be the farm that has been in their family for generations. Experts say there are no good, recent national data on how asset recovery is applied, with states differing drastically and working on a case-by-case basis.
It wouldn’t make sense for a state to pursue a claim on the property of a new Medicaid recipient under the health-care law, said Matt Salo, executive director of the National Association of Medicaid Directors.
“There’s no way any state is going to see it as cost-effective or politically sensible to do that,” he said. “It’s a scare tactic.”
Still, when it comes to something as central to middle-class identity as a home and what people can pass on to their heirs, it is perhaps not surprising that some people are not taking any chances.
..
after the Affordable Care Act made it mandatory for most people to carry health insurance, Oregon’s Medicaid office decided to change its approach because people scared about asset recovery were not signing up for coverage. New rules that took effect last year state that asset recovery now applies only to long-term care.
“We needed to take another look at heath insurance coverage from the point of view of it not being a public benefit that’s voluntary,” Mohr Peterson said.
Other states have taken a much more lax approach to asset recovery in the past, hesitant to target poor people whose only valuable asset might be the farm that has been in their family for generations. Experts say there are no good, recent national data on how asset recovery is applied, with states differing drastically and working on a case-by-case basis.
It wouldn’t make sense for a state to pursue a claim on the property of a new Medicaid recipient under the health-care law, said Matt Salo, executive director of the National Association of Medicaid Directors.
“There’s no way any state is going to see it as cost-effective or politically sensible to do that,” he said. “It’s a scare tactic.”
Still, when it comes to something as central to middle-class identity as a home and what people can pass on to their heirs, it is perhaps not surprising that some people are not taking any chances.
From the Web page of the Medical Expenditure Panel Survey
November 2013
Jeffrey A. Rhoades, PhD and Steven B. Cohen, PhD
Highlights
Approximately 20.4 million people, 7.6 percent of the population under age 65, were uninsured for the four-year period from 2008 through 2011. The percentage of long-term uninsured exceeded 10 percent for some younger adult age groups.
Adults ages 18 to 24 and 25 to 29 were the most likely to be uninsured for at least one month (48.0 and 46.9 percent, respectively) during 2010-2011. Children under age 18 were the least likely to be uninsured for the full four-year period from 2008-2011 (2.3 percent).
Individuals reported to be in excellent or very good health status were the least likely to be uninsured for at least one month during 2010 to 2011 (26.6 and 31.1 percent, respectively).
Hispanics were most likely to be uninsured for at least one month during 2010 to 2011 (47.8 percent) and for 2008-2011 (17.4 percent).
Hispanics were disproportionately represented among the long-term uninsured. While they represented 18.2 percent of the population under age 65, they comprised 41.5 percent of the long-term uninsured for 2008-2011.
Individuals who were poor, near poor, and low income were represented disproportionately among the long-term uninsured. While poor individuals represented 16.8 percent of the population under age 65, they represented 29.9 percent of those uninsured for 2008-2011.
Compared with other New England states, health status & preventive care improved in Massachusetts after reform – especially for poor & near-poor
ANN ARBOR, Mich. — In 2006, Massachusetts was on the same brink that the entire nation is on today: the brink of expanding health insurance to cover far more people than before, through government-driven, market-based reform.
Now, a new study shows the health of residents in that one trailblazing state improved measurably, especially among the poor and near-poor, in just the first five years — compared with the health of residents in neighboring states. So did the use of some preventive care, specifically two tests designed to spot colon and cervical cancers early, and cholesterol tests to gauge heart disease risk. The study was led by a University of Michigan Medical School researcher.
Meanwhile, over those same five years, Massachusetts residents were increasingly likely to say they had health insurance and access to a personal doctor, and less likely to say that costs stood in the way of getting care, than other New Englanders. The changes occurred at similar rates for black, white and Hispanic residents.
Writing in the new issue of The Milbank Quarterly, the study’s authors note that they can’t be certain that all the population-wide differences between Massachusetts and its neighbors came directly from the expansion of insurance coverage. Other reforms likely had an impact, too. But theirdetailed statistical analysis, supported by the Commonwealth Fund, points firmly to a positive impact, especially among residents with the lowest incomes.
“Everyone has been looking over the past few years at Massachusetts, which was the first state to show the rest of the U.S. that near-universal coverage could be achieved,” says first author Philip Van der Wees, Ph.D., a Dutch researcher who was at Harvard University when the study was conducted. “We found that people have gained in general, mental, and physical health, and that some preventive measures improved. We would hope that this would be a blueprint for the rest of the U.S., though Massachusetts is not the average state, because it began from a higher level of insurance,” among the state’s residents than the current U.S. average.
Van der Wees worked on the study with John Z. Ayanian, M.D., MPP, formerly of Harvard Medical School and now director of the University of MichiganInstitute for Healthcare Policy and Innovation, and with Harvard health care statistics expert Alan Zaslavsky, Ph.D. Van der Wees at the time was a Commonwealth Fund Dutch Harkness Fellow in Health Care Policy and Practice; he is now at Radboud University Nijmegen Medical Center in the Netherlands.
John Ayanian, M.D., MPP, director of the
U-M Institute for Healthcare Policy and Innovation
“Our results demonstrate the potential benefits of health care reform in Massachusetts that may also be achieved through the implementation of the federal Affordable Care Act,” says Ayanian.
“And, just as with the ACA, the impact of broader health insurance coverage in Massachusetts is intertwined with the effects of numerous efforts in the public and private sector to improve health care quality and contain costs,” he adds.
Statewide surveys reveal changes
The data for the study came from annual random telephone surveys during 2001 through 2011 that asked 345,211 New Englanders questions about their general, physical and mental health, and their use of and access to health care services including cholesterol testing and screening for cancers of the breast, colon and cervix. The data were gathered by state health departments in conjunction with the federal Centers for Disease Control and Prevention.
The researchers used advanced statistical approaches to study the data collected between 2001 and 2011 as part of the CDC’s Behavioral Risk Factor Surveillance System. This allowed them to detect subtle differences in health status and behaviors, and to analyze these differences further by income and race/ethnicity.
While the research didn’t show huge jumps in any particular area of health, care, or access, the overall pattern is consistent with a positive impact from increased health insurance and other reforms, compared with states that didn’t embark on major reform efforts. Even when the researchers excluded data from Vermont and Maine, which launched smaller-scale reform efforts, Massachusetts showed greater improvements.
The authors note that the “rising tide” effect in Massachusetts compared with other states was greater among those whose incomes were within 300 percent of the federal poverty level. These poor and near-poor residents had a faster rise in measures related to health care access and health status. The rate of changes in health status, access and care were similar among white, black and Hispanic residents, which means that deeply entrenched disparities in health likely persisted.
By studying access to care and health outcomes for five years after health reform took effect in Massachusetts, the authors also were able to distinguish how access to care and health outcomes changed over time. Whereas improvements in insurance coverage and reduced cost barriers to care were seen within one year after health reform, access to personal doctors improved after two years and gains in health status became evident after four years.
These statewide findings counter prior anecdotal perceptions that access to primary care worsened in Massachusetts after more residents gained insurance coverage.
The editor of the Milbank Quarterly, U-M Medical School professor Howard Markel, M.D., Ph.D., calls the study an important contribution to understanding of the potential implications of the federal Affordable Care Act.
“In an era of demagoguery and exaggeration posing as “facts” it is essential to collect and analyze solid evidence on our nation’s health care policies,” says Markel, the George E. Wantz Distinguished Professor of the History of Medicine and Director of the Center for the History of Medicine at U-M. “Indeed, it is the only way I know to approach the Sisyphean task of reforming and improving health care access for all Americans. Publishing and disseminating articles like this one is a solid start in that direction.”
At the time of the study, Ayanian was at the Harvard Medical School and School of Public Health, and the Brigham and Women’s Hospital. Now as director of U-M’s IHPI, he leads a group of more than 400 researchers – many of them focused on evaluating the impact of the Affordable Care Act and other changes in health care policy and practice.
Large coverage expansions under the Affordable Care Act have reignited concerns about physician shortages. The Association of American Medical Colleges (AAMC) continues to forecast large shortfalls (130,000 by 2025) and has pushed for additional Medicare funding of residency slots as a key solution.
These shortage estimates result from models that forecast future supply of, and demand for, physicians – largely based on past trends and current practice. While useful exercises, they do not necessarily imply that intervening to boost physician supply would be worth the investment. Here are a few reasons why.
1. Most physician shortage forecast modelsassume insurance coverage expansions under the ACA will generate large increases in demand for physicians. The standard underlying assumption is that each newly insured individual will roughly double their demand for care upon becoming insured (based on the observation that the uninsured currently use about half as much care). However, the best studies of this – those using randomized trials or observed behavior following health insurance changes – tend to find increases closer to one-third rather than a doubling.
2. A recent article in Health Affairs found that the growing use of telehealth technologies, such as virtual office visits and diagnoses, could reduce demand for physicians by 25% or more.
3. New models of care, such as the patient-centered medical home and the nurse-managed health center, appear to provide equally effective primary care but with fewer physicians. If these models, fostered by the ACA, continue to grow, they could reduce predicted physician shortages by half. 4. New research has shown that physicians do an enormous amount of work that can be handled competently by medical assistants, licensed practical nurses, social workers, pharmacists and others. Proper delegation to other health care professionals and non-professionals in this way can further reduce the need for physician labor and increase the efficiency of health care services — though providers will have to pursue these changes to the see the benefits.
5. Finally, the number of active physicians per-capitavaries by more than a factor of two across states in the US (Massachusetts has more than double the physicians per capita as Idaho) and even more across smaller regions. Though health care quality and access surely suffers in some areas, there is little correlation with physician supply overall – a testament to the fact that there is a very wide range of physician supply capable of supporting successful health care.
As modeling technology continues to evolve and the effects of ACA implementation become clearer, new models should be able to account for physicians’ shifting responsibilities and new ways of practicing. It is also certainly possible that new care models will place additional demands on physicians to manage their patients’ conditions and coordinate their care. Nevertheless, on the whole, the latest research suggests that calls to redirect taxpayer dollars to subsidize physician residencies may be premature.
David Auerbach is a policy researcher at the nonprofit, nonpartisan RAND Corporation.
Health care systems and single payer (Photo credit: Wikipedia)
I have a nagging question…is it right that health care is basically a for-profit industry?
Realize I need to clarify and expand on this in order for it to make sense.
However, in the past 20 or so years, I’ve seen the rise of medical complexes, “battles” among hospitals for market shares, huge increases in medical/health care advertising, and yet what seems to be a decline in the overall average health of Americans.
So, I have to ask…is this for-profit model working? And if not, what is the answer?
The math is not complex. Instead of doling out corporate welfare to insurance firms, we pay that money to deliver actual health care. As health improves, costs go down. “Single-payer allows citizens and businesses to win twice: — less money out of our individual budgets for health insurance, and — no government bureaucracy that gives our tax money to the less efficient health insurance companies through a variety of federal and state programs”http://www.medicareforall.org/pages/Terms_and_FactsOr we stick with corporate cons running the show and 31 million continue to suffer without health care.* This will raise costs of care and lead to more suffering. *{a report from the Congressional Budget Office (CBO) predicts that in the post-Obamacare world of 2023, 31 million, non-elderly Americans will remain uninsured.http://www.cbo.gov/publication/44190}
Oct 07, 2013 | Vernon K Smith, Ph. D., Kathleen Gifford, and Eileen Ellis of Health Management Associates,Robin Rudowitz and Laura Snyder
The dominant forces shaping Medicaid during FY 2013 and heading into FY 2014 were the implementation of the Affordable Care Act (ACA) and the development and implementation of an array of delivery and payment system reforms. These changes represent some of the most significant changes to Medicaid since its enactment in 1965, and taken together, are transforming the role of Medicaid in the health care system in each state. At this time, the intensity of fiscal pressures and the focus on cost Medicaid containment were somewhat lessened as the economy slowly recovers; however, controlling costs and improving program administration are still important priorities for Medicaid program. The findings in this report are drawn from the 13th annual budget survey of Medicaid officials in all 50 states and the District of Columbia conducted by the Kaiser Commission on Medicaid and the Uninsured and Health Management Associates (HMA). The report highlights trends in Medicaid spending, enrollment and policy initiatives for FY 2013 and FY 2014 with an intense focus on eligibility and enrollment changes tied to the implementation of the ACA as well as payment and delivery system changes. The report provides detailed appendices with state-by-state information and a more in-depth look at four case study states: Arizona, Florida, Kentucky and Washington. Key findings from the survey include the following:
Improvements in the economy resulted in modest growth in Medicaid spending and enrollment in FY 2013. In FY 2014, national enrollment and spending growth are expected to rise. States moving forward with the Medicaid expansion are expected to see higher enrollment and total spending growth driven by increases in coverage and federal funds.
The implementation of the ACA will result in major changes to Medicaid eligibility and enrollment for all states whether they are implementing the ACA Medicaid expansion or not.
Nearly all states are developing and implementing payment and delivery system reforms designed to improve quality, manage costs and better balance the delivery of long-term services and supports across institutional and community-based settings.
Improvements in the economy have enabled states to implement more program restorations or improvements in provider rates and benefits compared to restrictions, but states also adopted policies to control costs and enhance program integrity.
Looking ahead, FY 2014 will be a transformative year for Medicaid.
From the 9 September 2013 article by Kevin Pho at KevinMD.com
This column was published in USA Today on September 9, 2013.
More patients are coming to my primary care clinic with forms from their employer, asking me to measure their blood pressure, or check their sugar and cholesterol levels. Companies requesting medical data drive employee wellness programs, a booming $6 billion business, with approximately half of large employers offering such plans.
Coaching and financial incentives are often offered to help employees meet certain health metrics, such as losing weight, lowering cholesterol or quitting smoking. The results of these tests are often tied to the cost of health insurance, with less healthy workers paying more. Under the Affordable Care Act, up to 30% of an employee’s premium in 2014 can be influenced by these programs, an average of$1,620 annually per worker.
Wellness programs are designed to lower costs for employers and keep workers healthy, but do they accomplish either goal?
True health cost savings?
Wellness plans are often promoted as saving $3 or more for every dollar invested. But a recent RAND Corporation analysis found that fewer than half of companies took the time to calculate whether these programs saved them money. If they did, the numbers might have startled them. That same study also concluded that wellness programs did not significantly reduce employer health costs.
Why? Health screenings generally promote more doctor visits, prescription medications or further tests. While this might benefit workers’ health, it doesn’t necessarily save money.
If there are no measurable savings, employers pass on the cost of these programs, as much as $500,000 per year, to workers by raising their insurance premiums.
Whether wellness programs improve health is also dubious. This year, the California Health Benefits Review Program, which advises the state’s legislature, found that employees’ blood pressure, blood sugar or cholesterol did not improve by participating in a corporate wellness plan. Weight loss was minimal, with the RAND researchers finding that workers lost about 1 pound annually for three years.
Furthermore, there was no improvement in the rate of hospitalizations and emergency room visits.
Some short-term benefits
While there was a short-term gain in the rate of smokers quitting, it came with a qualification. Fewer than half of employees participate in wellness programs, which are mostly voluntary. Those who participate are often the most motivated, making it hard to tell whether their smoking cessation was due to the wellness program or the employees’ motivation.
Wellness programs also require tests more frequently. For instance, many require blood sugar and cholesterol screens every year in healthy adults, far in excess of recommended guidelines, which call for checking these levels once every three and five years, respectively. Such over-testing doesn’t necessarily make patients any healthier and contributes to the $210 billion our health system spends annually in unnecessary care.
Because I want my patients to save money on their insurance premiums, I dutifully fill out their wellness forms and order the requested screening tests that might not be needed. But it’s doubtful I’m saving these companies money or making my patients healthier by doing so.
From the 24 October 2013 article BY ANNE EIGEMAN at NonProfit Quarterly
As the most recent update in an ongoing research project that began in 2011, this week, the Blue Shield Foundation of California released a report on the healthcare experiences and expectations of low-income Californians. Two central goals guided the project: 1) to help healthcare facilities—particularly California’s community health centers—successfully navigate the changes brought about by the ACA, and 2) to help community health centers identify the most effective ways of encouraging patients and providers alike to embrace primary care redesign and move closer toward the goal of patient empowerment. As key findings, the study points to the “wide range of positive outcomes” that come from successful communication between patients and providers and the “broad gap” that currently exists between the information patients possess and the information they want.
The study found that only 28 percent of low-income Californians feel they have easily comprehensible health information for decisions about care. In addition, almost 40 percent rely on media sources to address concerns—“a potential problem” according to the study, because “trust in information is much higher when it comes from a medical professional than from other sources.”
A central theme is the value to patients that comes from a strong patient-provider relationship, which can lead to improvement in a patient’s overall sense of being well informed about his or her health, the level of satisfaction with the quality of care at a specific facility, and trust of the information provided by doctors. In light of upcoming structural changes to healthcare systems from the ACA, the study’s note that “alternative communication approaches also show great promise in helping to improve patients’ relationships with their providers.” is significant. Examples of these new approaches include team based care, decision aids, health coaches, and online or smartphone-accessible health sites, all of which were found to “enhance, rather than diminish, the critical connection between patients and their providers.”
The study devotes considerable attention to the effect of the digital divide on healthcare for specific groups of low-income Californians. “While four in ten low-income Californians overall lack Internet access, that soars to 67 percent of Spanish-speakers, 63 percent of non-citizens, 62 percent of Latinas and 59 percent of those in only fair or poor health,” the study reports. In addition, the fact that 59 percent of low-income residents over 50 lack Internet access and 41 percent lack a text-capable phone makes this “vulnerable population particularly hard to reach with technology-based information and communications.”
Population Health Implications of the Affordable Care Act is the summary of a workshop convened in June 2013 by the Institute of Medicine Roundtable on Population Health Improvement to explore the likely impact on population health improvement of various provisions within the Affordable Care Act (ACA). This public workshop featured presentations and discussion of the impact of various provisions in the ACA on population health improvement.
Several provisions of the ACA offer an unprecedented opportunity to shift the focus of health experts, policy makers, and the public beyond health care delivery to the broader array of factors that play a role in shaping health outcomes. The shift includes a growing recognition that the health care delivery system is responsible for only a modest proportion of what makes and keeps Americans healthy and that health care providers and organizations could accept and embrace a richer role in communities, working in partnership with public health agencies, community-based organizations, schools, businesses, and many others to identify and solve the thorny problems that contribute to poor health.
Population Health Implications of the Affordable Care Act looks beyond narrow interpretations of population as the group of patients covered by a health plan to consider a more expansive understanding of population, one focused on the distribution of health outcomes across all individuals living within a certain set of geopolitical boundaries. In establishing the National Prevention, Health Promotion, and Public Health Council, creating a fund for prevention and public health, and requiring nonprofit hospitals to transform their concept of community benefit, the ACA has expanded the arena for interventions to improve health beyond the “doctor’s” office. Improving the health of the population – whether in a community or in the nation as a whole – requires acting to transform the places where people live, work, study, and play. This report examines the population health-oriented efforts of and interactions among public health agencies (state and local), communities, and health care delivery organizations that are beginning to facilitate such action.
Source: George Washington University School of Public Health
A new report by the Geiger Gibson/RCHN Community Health Foundation Research Collaborative at the George Washington University School of Public Health and Health Services (SPHHS) examines the impact of health reform on community health centers (CHCs) and their patients. “Assessing the Potential Impact of the Affordable Care Act on Uninsured Community Health Center Patients: A Nationwide and State-by-State Analysis,” estimates that more than 5 million health center patients would have gained coverage had all states participated in a sweeping Medicaid expansion. However, nearly half of all CHCs are located in states that have opted out of the expansion. As a result, more than a million uninsured CHC patients who would have been covered under a nationwide Medicaid expansion will be left without the protection of health insurance, the report says.
Shin and his colleagues analyzed data from both the 2009 Health Center User Survey and the 2011 Uniform Data System to gauge the impact of the ACA on health center patients nationally and in all 50 states and the District of Columbia. Based on conservative assumptions, the analysis showed that over one million health center patients in the opt-out states who would have gained Medicaid coverage under an expansion will likely remain without insurance. These patients are very poor but do not qualify for the traditional Medicaid program and often cannot pay for health care – even at reduced fees, the study concludes. Ironically, these patients are also too poor to qualify for subsidies that would allow them to purchase health insurance at reduced rates on the new Health Insurance Exchanges.
The bottom line for the 518 health centers located in the opt-out states: the report says they’ll forgo approximately $555 million they would have received had their states expanded Medicaid, yet by law, they will still be treating all community residents, including those who lack health insurance or the means to pay for care.
“Health centers in the opt-out states will face an ongoing struggle to meet the need for care in medically underserved communities as a result of the potential loss of hundreds of millions of dollars in revenues in 2014 alone,” said Sara Rosenbaum, JD, the Harold and Jane Hirsh Professor of Health Law and Policy at SPHHS and a co-author of the report.
The report paints a very different picture for the 582 health centers in states that participate in the Medicaid expansion. Approximately 2.8 million patients at these health centers will gain coverage as a result of that decision. This added coverage will translate into a potential revenue increase of over $2 billion, which will support expanded staff and services.
States that have rejected the Medicaid expansion might reconsider and decide to expand coverage. Ohio’s just-announced Medicaid expansion is estimated to translate to over 63,000 residents gaining coverage and an additional $29 million in revenue gains in 2014 across 33 health centers. But in the near term, the report warns that many poor people living in the 25 opt-out states will continue to lack coverage and might find long wait times at clinics, long distances to find care, and other barriers that could translate to delays in treatment or no care at all. CHCs in those states will be unable to add much-needed services such as mental health or dental care, or to expand into remote or other seriously underserved areas—places where people have to travel for hours just to find a doctor.
“Community health centers represent the backbone of the nation’s safety net, providing high quality care to more than 20 million Americans who live in underserved neighborhoods,” says Feygele Jacobs, president and CEO of the RCHN Community Health Foundation. “Without the Medicaid expansion, CHCs in opt-out states will fall behind and will have trouble providing the kind of care that keeps people and communities healthy.”
Health Reform: Seven Things You Need to Know (Consumer Reports) [2012]- 15 pages with topics as newly enacted protections and benefits,what to expect in 2014, essential benefits defined, and how it will affect you
Health Insurance Marketplace– a great FAQ page with links to state information. Also answers to some specific questions as dental coverage, how to estimate costs, how to protect from fraud, and unemployed options
Earlier this week I attended a workshop for Ohio Benefit Bank volunteers. All sessions I attended addressed different aspects of the Health Insurance Exchange. The take home message was that while there are challenges, there is hope that overall ObamaCare will do more good than bad.
It is very important to go to reliable resources for unbiased and timely information about ObamaCare
I strongly recommend the resources** listed below
There will be glitches when the major provisions of the Affordable Care Act are implemented starting Oct. 1. Huge glitches. Many glitches. Bet on it.
That is a prediction not only from those resolutely opposed to the ACA. Even those quite excited about President Barack Obama’s federal health law have the same expectation: The rollout of the biggest new social program in nearly 50 years is not going to be pretty.
“When you’re dealing with tens of millions of new clients, mistakes are inevitable,” said Henry Aaron, a health economist at the Brookings Institution. “You’re going to have thousands of mistakes.”
…
“People can make comparisons to Medicare Part D and to Medicare itself, but nothing this big has ever been tried.”
In the simplest terms, the task at hand is to enroll 16 million currently uninsured Americans into health insurance plans or an expanded Medicaid. That process begins Oct. 1 with coverage starting Jan. 1.
…
Although Americans have until the end of March to sign up for health insurance, a crush of demand at the very start could overwhelm exchange call-in centers, websites and personnel. No one will say this out loud, but administrators are hoping for a steady trickle rather than a flood, at least in the early going.
All of the eligibility determinations and subsidy calculations will require a seamless transfer of information. The exchanges will have to interact with the U.S. Treasury for income information. They will have to communicate with the Department of Homeland Security to verify citizenship. And all this information must be handled without violating the privacy of consumers.
“CMS (the Centers for Medicare and Medicaid Services) has designed and tested a system that they think is going to work, and they know where the risks and vulnerabilities are,” said Charlene Frizzera, president of her consulting firm, CF Health Advisors, and a former acting administrator of CMS. “The question is, how will they deal with those vulnerabilities they anticipated and those they haven’t anticipated?
….
Dennis G. Smith, also a former head of what is now CMS, believes one weak point will be in the calculation of Medicaid eligibility. He believes it is likely that the exchanges and state Medicaid offices will use different formulas or time frames for determining eligibility, leading to frustration and confusion for many consumers.
“Exchanges will send a whole bunch of people to Medicaid and Medicaid will say ‘Nope, they don’t qualify,’ and send them back to the exchanges,…
…
states with federal exchanges are doing no outreach at all, which raises the possibility that residents of those states will remain uninformed and do nothing.
….
Even people who get the message may arrive at the exchanges having never before purchased health insurance and unfamiliar with the way premiums, co-pays and deductibles work. Others may lack documentation proving citizenship, residency and income.
…
Perhaps the question that causes the most trepidation in the Obama administration is whether healthy young people will sign up for health insurance as the ACA requires. Because young people tend to be healthy and file relatively few insurance claims, their premiums are supposed to help pay for claims of older, sicker people. If the only people buying insurance are old and the sick, insurance premiums will be prohibitively expensive…
Health Reform: Seven Things You Need to Know (Consumer Reports) [2012]- 15 pages with topics as newly enacted protections and benefits,what to expect in 2014, essential benefits defined, and how it will affect you
Health Insurance Marketplace – a great FAQ page with links to state information. Also answers to some specific questions as dental coverage, how to estimate costs, how to protect from fraud, and unemployed options
Many provisions of the Patient Protection and Affordable Care Act of 2010 have recently gone into effect, and some significant provisions will do so in 2014 and 2015. To help individuals and families, employers (both large and small), and other organizations learn more about how they’ll be affected, the IRS has launched a new website: IRS.gov/aca. The site offers information on the tax benefits and responsibilities for various groups, such as:
Individuals and families — new additional Medicare taxes, changes to the itemized medical expense deduction and open enrollment for the Health Insurance Marketplace
Employers — determining whether you’re a large or small employer, shared responsibility payments for large employers, and the small business health care tax credit
Other organizations — tax provisions for insurers, certain other business types and tax-exempt and government organizations
Great 7 minute overview, published by KaiserHealthCare. Really liked how the graphics (including Playschool like cartoon figures) outlined the major points without making me feel like a dummy!
Do you have a good sense of what the new health care options are starting 2014? The HR folks at work just shared this cute 7minute video that does a good job of clarifying what the options are and the advantages and disadvantages of each. I found it really useful and thought I’d pass it along.
” Individual exchanges in 34 states will be created via the federal government – but on July 5, it quietly granted another concession. The Department of Health and Human Services relaxed a requirement for the 16 other states and the District of Columbia to verify the income and health coverage status of applicants to those individual exchanges. These 17 exchanges will only check the income eligibility of applicants at random next year, and they will wait until 2015 to check if applicants are getting employer-sponsored health benefits.5″
“Where do things stand state-by-state with the Medicaid expansion? Just 23 states and the District of Columbia have signed up for it. (You’ll recall that the Supreme Court allowed states to opt out of it when it ruled that the ACA was constitutional in 2012.) In these states and in Washington D.C., those with earnings of up to 138% of the federal poverty level may qualify for Medicaid (that works out to earnings of $15,856 for an individual and $32,499 for a family of four). The expansion of Medicaid in these states doesn’t require the federal government to recreate the wheel, but delays could happen in other ways. In Michigan, for example, state legislators have passed their own version of a Medicaid expansion requiring a 90-day federal review process, which will put Michigan weeks behind in enrolling participants in expanded Medicaid coverage.6,”
As a late 20-something, I could very possibly be a member of the “young invincibles,” a label used to describe people between 18 and 34 who do not have health insurance because they think they’re, well… invincible (not to mention broke).
I lucked out in that five years ago, I somehow found myself working for the largest private statewide health foundation in California, dedicated to improving the health status of underserved populations in California. The ability for communities to have solid access to health care is one of our core values. As a reflection of this value, a variety of health insurance options are provided to our employees at a very affordable rate.
As most of us know, not everyone is so lucky. Recently, at a party during a “what do you do” conversation, a freelance screenwriter (struggling to make ends meet) asked me what he could do to get health insurance being single, unemployed, and having a few health issues to tackle. He, like many of us, will be required to have health insurance pretty soon. But beyond that, we don’t know much. So I spent some time today leafing through healthcare.gov and other sites with any 411 to get the quick down-and-dirty of what we all need to know going into January 1, 2014, when most of us will be required to have health insurance.
Visit USA.gov’s Health Insurance page to learn about the new Health Insurance Marketplace and other types of health coverage.
Starting October 1, 2013, you can fill out an application for health insurance through the Health Insurance Marketplace. You’ll be able to compare your options side-by-side and enroll in a plan that fits your budget and meets your needs. Coverage takes effect as early as January 1, 2014.
USA.gov’s Health Insurance page includes:
A brief overview on health insurance and the Affordable Care Act.
Key dates for enrollment and coverage through the Health Insurance Marketplace.
Publications to help you prepare for enrollment through the Health Insurance Marketplace.
Information about Medicaid, Medicare, the Children’s Health Insurance Program, and COBRA.
While I’ve been busy with other things, I let this issue raised at ALA slip past unnoticed. Issues in library world don’t go unnoticed for very long, especially when they deal with government intrusion. Apparently, during ALA 2013 Conference a video was played in which there was a White House appeal to public librarians to help Americans understand the new Affordable Healthcare Act insurance system that goes into effect whenever – maybe.
I am hoping that the federal government can do a bit more to provide resources for librarians about ACA.
Back in my public library days, it wasn’t easy working with patrons when the topic was against my views!
However, I always tried to address people’s information needs without bias and as completely as possible with factual information.
“ObamaCare” questions are in the same arena. While librarians cannot advise or fill out forms, they can at least lead folks to factual information. However, this would work best if the federal government would do everything possible to lighten the load for libraries. This would include providing readable materials for consumers, as well as “pathways” for librarians.
Also, libraries can welcome trained volunteers and organizations to give in-depth information to folks. Many already do this around tax time with IRS trained volunteers.
Here in Toledo, folks from legal aid organizations “set up shop” in public libraries to assist folks. Representatives from the Ohio Benefit Bank do likewise. These volunteers screen people for government assistance programs as SNAP and the Medicare Savings Program.
It sure would be great if government employees and/or trained volunteers could do likewise for “ObamaCare”. Areas could include the health exchange marketplace, Medicaid expansion, free preventative care, and more.
And with articles as this, there is a real need for information professionals, including librarians!
Ohio insurance regulators Thursday released rates for health insurance to be sold on the new state marketplace and said premiums for individuals will rise an average of 41 percent compared with 2013 rates.
That average brought immediate condemnation from critics of the Affordable Care Act, with U.S. House Speaker John Boehner, a southwest Ohio Republican, calling it “irrefutable evidence” that the law known as Obamacare is driving up costs and hurting the economy……..
US consumers don’t understand health insurance, Carnegie Mellon research shows (Medical News Today, 2 August 2013)
“…only 11 percent of respondents presented with a traditional insurance plan incorporating all four of these elements were able to compute the cost of a four-day hospital stay when given the information that should have enabled them to do so…
“”The ACA deals with the problem of consumer misunderstanding by requiring insurance companies to publish standardized and simplified information about insurance plans, including what consumers would pay for four basic services,” noted lead author Loewenstein. “However, presenting simplified information about something that is inherently complex introduces a risk of ‘smoothing over’ real complexities. A better approach, in my view, would be to require insurance companies to offer truly simplified insurance products that consumers are capable of understanding.”
I am hoping that the federal government can do a bit more to provide resources for librarians about ACA.
Back in my public library days, it wasn’t easy working with patrons when the topic was against my views!
However, I always tried to address people’s information needs without bias and as completely as possible with factual information.
“ObamaCare” questions are in the same arena. While librarians cannot advise or fill out forms, they can at least lead folks to factual information. However, this would work best if the federal government would do everything possible to lighten the load for libraries. This would include providing readable materials for consumers, as well as “pathways” for librarians.
Also, libraries can welcome trained volunteers and organizations to give in-depth information to folks. Many already do this around tax time with IRS trained volunteers.
Here in Toledo, folks from legal aid organizations “set up shop” in public libraries to assist folks. Representatives from the Ohio Benefit Bank do likewise. These volunteers screen people for government assistance programs as SNAP and the Medicare Savings Program.
It sure would be great if government employees and/or trained volunteers could do likewise for “ObamaCare”. Areas could include the health exchange marketplace, Medicaid expansion, free preventative care, and more.
And with articles as this, there is a real need for information professionals, including librarians!
Ohio insurance regulators Thursday released rates for health insurance to be sold on the new state marketplace and said premiums for individuals will rise an average of 41 percent compared with 2013 rates.
That average brought immediate condemnation from critics of the Affordable Care Act, with U.S. House Speaker John Boehner, a southwest Ohio Republican, calling it “irrefutable evidence” that the law known as Obamacare is driving up costs and hurting the economy……..
While I’ve been busy with other things, I let this issue raised at ALA slip past unnoticed. Issues in library world don’t go unnoticed for very long, especially when they deal with government intrusion. Apparently, during ALA 2013 Conference a video was played in which there was a White House appeal to public librarians to help Americans understand the new Affordable Healthcare Act insurance system that goes into effect whenever – maybe. This federal initiative to get public libraries involved in assisting people to sign up goes into effect October 1.
CHICAGO — The nation’s librarians will be recruited to help people get signed up for insurance under President Barack Obama’s health care overhaul. Up to 17,000…
Open enrollment for the Affordable Care Act Health Information Marketplace, formerly referred to as the “Health Insurance Exchange”, begins October 1, 2013. But did you know that you and your patrons can start collecting information now? According to the HealthCare.gov Marketplace Application Checklist, the following items will be needed for those planning to apply for coverage:
Social Security Numbers (or document numbers for legal immigrants)
Employee and income information for every member of your household who needs coverage (for example, from pay stubs or W-2
forms—Wage and Tax Statements)
Policy numbers for any current health insurance plans covering
members of your household
A completed Employer Coverage Tool for every job-based plan you or someone in your household is eligible for.
States had the option of either setting up their own insurance marketplaces under Obamacare, or leaving that work for the federal government to do. Many GOP-controlled states resisted cooperating with the health reform law under any circumstances and refused to set up marketplaces on their own. In Missouri, lawmakers actually went a step further and enacted measures to prevent state officials from providing “assistance or resources of any kind” to the federal government’s effort to establish a marketplace. The New York Times reports that’s essentially encouraged confusion among Missouri residents, who have no idea how to enroll in Obamacare plans….
……
Across the country, Obamacare opponents have launched a coordinated misinformation campaign about the health reform law, confusing Americans about what the upcoming changes will mean for them. A survey of health care-related advertising in June found that Obamacare critics have outspent its supporters by a nearly five to one margin. And last month, the Koch Brothers poured millions more into a new Obamacare misinformation campaign. Anti-Obamacare groups are now launching grassroots initiatives to actively dissuade people from enrolling in the new insurance marketplaces — telling young Americans to “burn your Obamacare draft card.”
These campaigns could have serious consequences for Americans across the country. There’s a limited enrollment period for the new Obamacare plans in the state-level marketplaces. The initial enrollment period will be extended until March 2014 — but after that, people will only be able to sign up for coverage in between October and December. If they can’t figure out how to do it, or if they’ve been persuaded to simply forgo health plans in the marketplaces, they’ll be forced to go uninsured for the rest of the year even if they end up changing their minds….
An aside…
Twice a week I volunteer at a soup kitchen/clothing distribution center. And three times a week I make phone calls screening folks for the Social Security Extra Help program which helps very low income people with their prescription drug costs.
English: U.S. Health Insurance Status (Under 65) (Photo credit: Wikipedia)
I advocated for the Affordable Care Act, and celebrated when it was passed.
It’s good to have everyone covered, I thought.
Insurance for everyone is the first step to health care for all.
Alas, access to health insurance isn’t the same as access to health care.
First there is the niggling detail of providers. We already have a primary care provider shortage. Internists, pediatricians, family physicians are already working at full capacity in caring for the general health needs of a community. The poorest neighborhoods with the worse reimbursements already have a severe shortage of providers. More people with health care coverage, means more people will be seeking routine care, and we don’t have more providers ready to see them all.
For patients, this will mean longer waits to see a provider. Or for providers, it will mean longer hours at work to see more patients.
Second, the ability to buy subsidized health insurance doesn’t automatically mean the ability to pay for health care.
I just learned that patients who are unable to pay their co-pays within 90 days may then need to face the entire medical bill on their own. How bad can a co-pay be, you may ask?
“When I say I have zero income, that means I have no money. None,” said one of my patients from the community health center where I work as a family physician on the South Side of Chicago, when I was encouraging him to buy generic medications at Walmart or Target. “$4 is too much for me,” he said. “I’d need to steal to buy it. “
Zero income means an enormous challenge to pay anything, borrowing from a network of friends and relatives and searching out social programs for medical assistance. In some states, Medicaid will be expanded to cover everyone who is near the federal poverty line. Other states are choosing not to expand coverage to young men. Private insurance plans may effectively leave them unable to afford health care, even if they are able to afford subsidized health insurance on the state exchanges.
When patients who live on the financial edge, who currently don’t have health insurance miss their co-payments, they will become liable to pay the entire cost of the doctor’s visit. After 90 days with no co-pay, then insurance companies would owe nothing. The people who are poorest , who have the toughest time scraping together the money to cover their co-pays, may ultimately be responsible for paying not only their co-pay, but the entire medical bill, while also paying insurance premiums.
This would be unfortunate.
I wish we could turn back the clock and create a simpler system where everyone had access to care without needing to worry about who pays what. Instead we have recreated pricing mechanisms that in effect result in tiered payments where the poorest patients continue to pay the most.
People are poised to buy into a broken system at the stroke of midnight announcing January 1, 2014.
The health insurance exchanges are coming—faciliating the buying and selling of imperfect products that promise access they can’t fully deliver, while potentially leaving vulnerable patients without full access to health care.
And still this is better than the alternative, where patients had no coverage at all, and the system wasn’t incentivized to find ways to become more efficient and more effective.
There will be new incentives in healthcare. We’ll see what happens. The American healthcare system will need to continue to adjust to the needs of patients, to be responsive to the most vulnerable, in order to ensure a healthier America.
Kohar Jones is a family physician who blogs at Progress Notes.
Importance
Physicians’ views about health care costs are germane to pending policy reforms.
Objective
To assess physicians’ attitudes toward and perceived role in addressing health care costs.
Design, Setting, and Participants
A cross-sectional survey mailed in 2012 to 3897 US physicians randomly selected from the AMA Masterfile.
Main Outcomes and Measures
Enthusiasm for 17 cost-containment strategies and agreement with an 11-measure cost-consciousness scale.
Results
A total of 2556 physicians responded (response rate = 65%). Most believed that trial lawyers (60%), health insurance companies (59%), hospitals and health systems (56%), pharmaceutical and device manufacturers (56%), and patients (52%) have a “major responsibility” for reducing health care costs, whereas only 36% reported that practicing physicians have “major responsibility.” Most were “very enthusiastic” for “promoting continuity of care” (75%), “expanding access to quality and safety data” (51%), and “limiting access to expensive treatments with little net benefit” (51%) as a means of reducing health care costs. Few expressed enthusiasm for “eliminating fee-for-service payment models” (7%). Most physicians reported being “aware of the costs of the tests/treatments [they] recommend” (76%), agreed they should adhere to clinical guidelines that discourage the use of marginally beneficial care (79%), and agreed that they “should be solely devoted to individual patients’ best interests, even if that is expensive” (78%) and that “doctors need to take a more prominent role in limiting use of unnecessary tests” (89%). Most (85%) disagreed that they “should sometimes deny beneficial but costly services to certain patients because resources should go to other patients that need them more.” In multivariable logistic regression models testing associations with enthusiasm for key cost-containment strategies, having a salary plus bonus or salary-only compensation type was independently associated with enthusiasm for “eliminating fee for service” (salary plus bonus: odds ratio [OR], 3.3, 99% CI, 1.8-6.1; salary only: OR, 4.3, 99% CI, 2.2-8.5). In multivariable linear regression models, group or government practice setting (β = 0.87, 95% CI, 0.29 to 1.45, P = .004; and β = 0.99, 95% CI, 0.20 to 1.79, P = .01, respectively) and having a salary plus bonus compensation type (β = 0.82; 95% CI, 0.32 to 1.33; P = .002) were positively associated with cost-consciousness. Finding the “uncertainty involved in patient care disconcerting” was negatively associated with cost-consciousness (β = −1.95; 95% CI, −2.71 to −1.18; P < .001).
Conclusion and Relevance
In this survey about health care cost containment, US physicians reported having some responsibility to address health care costs in their practice and expressed general agreement about several quality initiatives to reduce cost but reported less enthusiasm for cost containment involving changes in payment models.
The increasing cost of US health care strains the economy. Because physicians’ decisions play a key role in overall health care spending and quality, several recent initiatives have called on physicians to reduce waste and exercise wise stewardship of resources.1- 4 Given their roles, physicians’ perspectives on policies and strategies related to cost containment and their perceived responsibilities as stewards of health care resources in general are increasingly germane to recent pending and proposed policy reforms.5 We surveyed US physicians about their views on several potential proposed policies and strategies to contain health care spending, assessed physicians’ perceived roles and responsibilities in addressing health care costs, and ascertained physician characteristics associated with those views.
English: President Barack Obama’s signature on the health insurance reform bill at the White House, March 23, 2010. The President signed the bill with 22 different pens. (Photo credit: Wikipedia)
In June 2012, the Supreme Court ruled on the constitutionality of key components of the Affordable Care Act; and foremost among these were the individual mandate and Medicaid expansion. The Court judged the former to be constitutional but allowed states to “opt out” of the Medicaid expansion and some states have indicated that they will exercise this option. How might state choices affect health care coverage and costs?
The Patient Protection and Affordable Care Act (ACA) provides for three basic ways to increase health insurance coverage: the expansion of Medicaid to cover the poorest population; the provision of subsidies for those with low or medium incomes to purchase coverage on the new health insurance exchanges; and the institution of an individual mandate requiring everyone to have insurance. Taken as a whole, the ACA is highly controversial. However, Medicaid expansion and the individual mandate are particularly contentious issues, and the constitutionality of both was challenged, ultimately landing on the docket of the Supreme Court.
In June 2012, the Court ruled that the individual mandate was constitutional but gave states the option of not participating in the Medicaid expansion slated to begin in 2014. As of the spring of 2013, governors from 14 states had indicated publicly that they will choose to opt out.
The state-by-state breakdown as of spring, 2013. States where governors have stated they will not expand Medicaid are indicated in white, states that are leaning toward opting out or seeking alternative options are indicated in gray, and the remainder are red.
Source: The Advisory Board Company
What does Medicaid expansion offer states?
More federal Medicaid funds: Under the ACA, the federal government will pay 100 percent of the coverage costs for those newly insured under Medicaid expansion. After 2016, the federal share gradually shrinks to 90 percent, substantially more than the 57 percent they currently pay on average.
Greater access to care for the poor: Medicaid expansion makes health care more accessible to the poorest segment of the population — those earning less than 138 percent of the federal poverty level (this amounts to an income of about $16,000 for a single person or $32,000 for a family of four in 2013).
Reduced outlays for uncompensated care: Providing insurance to the very poor reduces uncompensated costs of treatment for this group — an estimated $80 billion in 2016. Currently, about one-third of these expenditures come from state coffers.
Reduces financial risk for the lowest-income Americans: Analysis of Oregon’s Medicaid experiment found that the financial hardship associated with medical coverage was dramatically reduced.
The report goes on to explain
Without Medicaid expansion, the poorest population could fall through a coverage gap.
What could be done about the coverage gap for low-income populations?
From the 9 April 2013 article at the National Partnership for Action to End Health Disparities
The Office of Minority Health Knowledge Center supports National Minority Health Month by highlighting many information resources available to the public. The Knowledge Center focuses its collection on consumer health and many other health equity issues, and builds on this year’s theme ofAdvance Health Equity Now: Uniting Our Communities to Bring Health Care Coverage to All.
Created in 1987, the Knowledge Center indexed and tracked the concept of health disparities in the available literature long before it appeared in the forefront of public health concerns. Today, the library offers both a historical and present day picture of the health status of minority populations and holds a collection of 10,000 reports, books, journals and media, and over 35,000 articles, which makes it the largest repository of minority health information in the nation.
Equal access to health care has long been a factor in health equity, and the Knowledge Center library catalog reflects those concerns. By searching our catalog, you will find many reports, books and fact sheets which explain disparities in access to health insurance and health care.
And the Knowledge Center is more than a library. We also contribute to the outreach and educational activities of the Office of Minority Health and reach out to other libraries to support their consumer health education initiatives. For example, a recent presentation and exhibit at the Joint Conference of Librarians of Color highlighted our services and resources for public and academic libraries.
Other libraries have found ways to advance health equity, in keeping with objectives set by our National Partnership for Action (NPA). As an NPA partner, the University of Maryland Health Sciences and Human Services Library developed a health advocates program for local high school students (read more about the program.)
With 35 languages represented in our collection, the Knowledge Center is open to the public for research about a variety of diseases and health topics and you can search the database right from your desktop.
We invite you to take a look at our online catalog and conduct a search. Enter the search terms “Affordable Care Act” and discover what OMHRC has to offer you.
In a November article for the New England Journal of Medicine, Harvard law professors Michelle Mello and Glenn Cohen argue that in upholding the Affordable Care Act’s individual insurance mandate as a tax the Supreme Court “has highlighted an opportunity for passing creative new public health laws.” As a bioethicist who writes extensively on the question of coercive public health this troubled me on several fronts. In this case, Mello and Cohen give an example of the laws that they have in mind: higher taxes on people whose body-mass index falls outside of the normal range, who do not produce an annual health improvement plan with their physician, who do not purchase gym memberships, who are diabetic but fail to control their glycated hemoglobin levels, and who do not declare that they were tobacco-free during the past year.
…So while I am heartened by how consumer-driven health care has become – retail clinics, quality rankings as examples – I’m reminded that we are only as consumer-centric as our weakest link(s). For every example I have, I know that there are many more. There are plenty of weak links throughout the healthcare system. Like Kohl’s, each of us can look at the top things that make our business difficult for people to deal with. With often only modest effort, we can make changes to significantly improve the consumer experience, lower frustration and minimize confusion……
This blog presents a sampling of health and medical news and resources for all. Selected articles and resources will hopefully be of general interest but will also encourage further reading through posted references and other links. Currently I am focusing on public health, basic and applied research and very broadly on disease and healthy lifestyle topics.
Several times a month I will post items on international and global health issues. My Peace Corps Liberia experience (1980-81) has formed me as a global citizen in many ways and has challenged me to think of health and other topics in a more holistic manner.
Do you have an informational question in the health/medical area? Email me at jmflahiff@yahoo.com I will reply within 48 hours.
My professional work experience and education includes over 15 years experience as a medical librarian and a Master’s in Library Science. In my most recent position I enjoyed contributing to our library’s blog, performing in depth literature searches, and collaborating with faculty, staff, students, and the general public.
While I will never be be able to keep up with the universe of current health/medical news, I subscribe to the following to glean entries for this blog.
Publication Date:
Michelle Andrews
The state-by-state breakdown as of spring, 2013. States where governors have stated they will not expand Medicaid are indicated in white, states that are leaning toward opting out or seeking alternative options are indicated in gray, and the remainder are red.
Health and Medical News and Resources 
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