Fall Conference Demo Submission Deadline EXTENDED to 7/7/17

Have an innovative product or solution you want to showcase to the entire health care community?
Show us what you got! Live demos are standalone, but they’re often interspersed into larger panel sessions with commentators reflecting on the demo and how they believe it fits into health care. The 3.5-minutetechnology demos are a major hallmark at the Health 2.0 conferences. We do mean LIVE – no PowerPoint or video allowed!
We review submissions on a first-come, first-serve basis. If you’re uncertain that your product will be completely ready at the time of the conference, let us know of your interest anyway – we like to know what’s going on in the community, and it’s not unusual for us to show products in early stages, too!
To learn more and apply, click here! 

Check out a demo video from last year’s Fall Conference:DUE Friday July 7, 2017 11:59 PM PST

Jill Merrigan is the Marketing Manager of Health 2.0.

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Time to Start Over!

By STEVE FINDLAY

The CBO’s analysis of the House and Senate health bills should kill them both—permanently.

Republicans should go back to the drawing board and work with Democrats in both the House and Senate to achieve bipartisan fixes to the ACA/Obamacare marketplaces for 2018 and 2019.

That is the far and away the best thing to do from a policy and political perspective.   The vast majority of Americans would stand up and cheer. Two polls out this week, for example, add to previous surveys showing deeply low public support for the Republican bills.

A USA TODAY/Suffolk University poll found that just 12 percent of Americans overall support the Senate Republican plan, including only 26 percent of Republicans. Similarly, an NPR/PBS NewsHour/Marist poll found 17 percent in favor overall, with Republican support at 35 percent.

Just 25 percent of respondents in the latter poll say the want Congress to repeal the ACA completely—consistent with other polls since late 2016.

Trump has suggested a bipartisan path several times in recent months, although there’s no evidence he ever reached out to Democrats and he just as frequently demonized them as “obstructionists.”

That Trump does not now see that he’d likely be hailed a hero if he brought the two sides together on this issue is a failure of judgment and leadership, in my view.

Recognizing the importance of optics to this President, even Obama has said Trump and Congress can call whatever emerges a “repeal” of Obamacare if they want.

Working together, Republicans and Democrats should first and foremost stabilize the exchanges by means of these and other measures:

(1) Increase premium subsidies/tax credits for low-income people

(2) Enact some hybrid of the exchange market stabilization funds in the House and Senate bills. Those earmarked between $10 and $20 billion a year to reduce premiums where needed, subsidize insurers for very expensive claims, attract new insurers in poorly served areas, and expand enrollment of healthy young and middle aged people.

(3) Fund the cost saving reduction (CSR) payments—deductible and co-pay help—in full for two to three years—at $7 to $10 billion per year.

(4) Bring back the reinsurance fund for insurers. This operated from 2014 to 2016, helping to defray insurers costs for outlier claims and thereby reducing premiums by 5% to 10% a year. The temporary program’s termination was one factor in the average 22 percent increase in premiums across the country in 2017.

(5) Provide additional funding to states to allocate to insurers to ramp up opioid addiction and substance abuse/mental health treatment. The Senate bill provided $2 billion for this over 10 years. Much more is needed—on the order of $1 to $3 billion per year.

(6) Provide more funding to the nationwide network of community health centers. With a history of bipartisan support, the 1,300 centers serve the medical needs of about 25 million low-income people. Since the ACA was enacted, the centers have steered millions of people to sign-up for exchange coverage or Medicaid. Under current law, they will receive about $4 billion in federal funds in 2017. The Senate bill increases that by $422 million.   The centers should get an additional $1 billion or so for 2017 and 2018.

(7) Expand section 1332 of the ACA to make it easier for states to experiment with their insurance systems as long as those experiments obey the ACA’s insurance rules on consumer protections and do not increase the number of people without coverage nor cost the federal government more money.   (Hey, if California, Vermont or Massachusetts want to enact a single payer system with their own money, let them do it. The current effort in Calif. appears to be dead in the water for this year.)

The House and Senate bill’s Medicaid overhaul should be abandoned and the Medicaid expansion component of the ACA retained. Long-term fixes to that program are needed but should not be taken up now.

Lost their way

The CBO verdicts on both bills show us that Republicans lost their way. Many commentators have said the process was purely political—with little attention to the actual policies they were proposing.

I don’t buy that.  Yes, Republicans are guilty of political hubris, legislative overreach, and an exclusionary process that ignored congressional norms. But they are also guilty—with full awareness of the impact—of trying to undo 52 years of a delicately balanced federal-state partnership (Medicaid) to serve the health needs of low-income Americans, including millions of seniors and children. And they are guilty, most cynically, of proposing to dramatically reduce the growth in Medicaid spending to deliver a tax cut to the wealthy and to corporations.

This is a disturbing place to be for our nation. For the second time in a decade, we are debating whether social insurance and guaranteed universal health coverage are good ideas. Every other modern, industrialized democracy—and most other non-democratic wealthy nations—long ago resolved this issue. That includes the conservative parties in those countries.

Other nation’s leaders and their people embrace both concepts because no matter what your political views or values, both concepts (in tandem in health care) deliver multiple benefits.

Broad social insurance and a universal coverage system don’t just assure people access to health care. They create social equality and stability, and enhance employment, productivity and economic growth by keeping larger portions of the population healthy and working.

Absolutely alone, the Republican party in the United States is the only political entity in the western developed world that does not concur that an egalitarian social insurance approach to health care is the most efficient one.

Also, shamefully, Republicans propose their alternative “free-market” path even as research reveals a USA where: (a) racism remains a poisonous force that still divides us (Black and Hispanic Americans are much more likely to lack coverage and die younger); (b) the premature death rate among low-income white Americans is increasing for the first time in decades; (c) as many people are dying of drug overdoses and related afflictions as traffic accidents; and (d) mental health problems such as depression, anxiety and PTSD are on the rise and more prevalent than in other OECD countries.

The House and Senate bills are mean. The impulse and philosophy behind them pretends to be mostly about reining in long-term federal spending, creating more competition in health care, giving consumers more choice, removing government mandates on businesses and people, and giving states more flexibility (although mostly to spend their own tax dollars.)

To be fair, some of that agenda should be in play. More competition among insurers and in doctor’s fees, health products, and prescription drug prices—would be welcome. And the growth in health costs and spending will have to be constrained; it’s unsustainable after about 2024.

But neither the House nor Senate repeal bills lift a finger to reduce underlying health care costs. Instead, they shift the burden of rising costs to states, businesses, and consumers/families.

Sadly, the more foundational Republican philosophy in this legislation is social Darwinism: The fittest survive and thrive. The poor are that way, and usually sicker, because—well, they just are. People are ultimately responsible for their health; government is not responsible.   We spend too much money on the poor. We are not a European welfare state. This is not a socialist country. You make your own way here. No handouts. You gotta earn your insurance, and have “skin in the game.” Medicaid is just a welfare program.

It’s all right there in Kellyanne Conway’s telling comment on a talk show this past Sunday: “People who lose Medicaid should just get a job with benefits.”

You can read the CBO report or the handy summary on CBO’s web page.        It’s a straightforward 49-page document.

I concur with Vox’s terrific health policy reporter Sarah Kliff that Table 5 on page 48 is especially worth checking out.   It shows, for example, that a 64 year-old single person with an income of $56,000 who opts for a silver plan would pay an estimated net annual premium (after subsidies) of $6,800 in 2026 if current law (the ACA) is maintained. Under the Senate bill, this person would pay a net premium of $20,500.

In contrast, a 21 year-old buying the same silver plan would see their net premium decline by $1,000, from $5,100 to $4,100 by 2026 under the Senate bill, compared to the ACA.

From the CBO’s summary:

“Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up.”

By 2020, average premiums for single individuals would decline by about 30 percent compared to current law, however, CBO predicts. Hmmm, that sounds good.   It’s not. Why? Because the decline is due in large part to, in CBO’s words, “the smaller share of benefits paid for by the benchmark plans.”

Translation: Premiums would decline because people would be buying policies that had a significantly lower actuarial value (close to 55%), much higher deductibles ($6,000 and up) and co-pays, and possibly fewer benefits as a dozen or more states opt out of the ACA mandated essential health benefits.

The CBO’s predicted loss of insurance by 22 million people by 2026 (15 million in 2018) stems from six key provisions in the Senate bill, according to a nice summary from the Commonwealth Fund:

  • Smaller premium tax credits compared to the ACA that make coverage less affordable for low-income people
  • The ability of insurers to charge older people premiums up to five times more than they charge young people, making coverage much more expensive for older people
  • Higher deductibles and copayments that make coverage less valuable for everyone
  • A phase-out of the Medicaid expansion starting in 2020 that reduces coverage for low-income people
  • A $772 billion reduction in federal funds over 2017–2026 for state Medicaid programs that could leave children, disabled people, and the elderly with fewer or no benefits

 

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Did “Medicus economicus” kill Medicare Part B Reform?

When doctors complain about proposed changes to health care reimbursement, do they speak for patients or their pocketbooks? As the recent debate over Medicare Part B shows, even with access to publicly available billing data, it’s hard to disentangle financial motivations from more altruistic ones.

Since 2005, Medicare Part B has paid for physician-administered drugs like infused chemotherapeutics by reimbursing 106% of the average selling price (ASP) – a formula commonly referred to as “ASP+6”. In order to reduce overall spending and the program’s apparent incentive for physicians to preferentially use high-priced drugs, CMS proposed a pilot program last year to test a new payment formula that would have reduced the 6% markup to 2.5%, but added a flat per-infusion payment – effectively rewarding doctors more for choosing cheaper drugs, and reducing their profit from expensive ones.

The plan to revamp Part B reimbursement was scrapped after many groups – including professional organizations representing cancer doctors – vigorously objected. Oncologists argued that there are few cases in which a cheap anti-cancer drug is therapeutically equivalent to a more expensive one, and that the proposed change would mainly harm oncologists’ ability to provide high-quality care.

These may be valid arguments, but it’s hard to disentangle oncologists’ clinical interests from their financial ones. Many economists might reasonably view cancer doctors who object to Part B reform as the physician manifestation of “Homo economicus,”<> acting solely to maximize their personal gain. Neeraj Sood at the University of Southern California summed up many observers’ knee-jerk response: “Doctors are human. The fact is, this [new proposed] model changes how much money they’ll make.”

But that raises a key question: how much do oncologists make from “ASP+6,” anyway? If cancer doctors rely on Part B profits for much of their income, then it’s more plausible to think that economic self-interest played a big role in their opposition to the pilot program – but if the proposed change to Part B would have had a minor impact on doctors’ take-home pay, then this trivial explanation is less compelling. Prior analyses have measured the relative decrease in profit the new formula would have engendered across all oncologists and for individual drugs, but they haven’t converted this percentage into actual dollars per doctor.

At first blush, it appears that Part B profits could account for a sizable fraction of take-home pay. We estimate that the median oncologist who billed for drugs under Part B in 2014 earned $29,900 of profit (interquartile range, $13,586-$49,954) from the Medicare fee-for-service population, which is just under 10% of the median oncologist’s income – but this is likely the low end of the range. (See footnote for methods.) The CMS database doesn’t include drug-related income from older adults covered by Medicare Advantage or private payers, or from the almost 50% of cancer patients who are younger than Medicare age. (Although other payers besides traditional Medicare typically pay more than a 6% mark-up, it’s likely they would at least somewhat follow Medicare’s lead if “ASP+6” were changed.) Although it’s hard to calculate precise numbers without knowing the exact payer splits and mark-ups in the typical oncologist’s practice, our analysis and a recent benchmarking study together suggest that Part B income is a fairly substantial chunk of the net profit generated by each doctor.

But this back-of-the-envelope calculation may mask a high degree of skewness in the distribution of these data. Of the almost 12,000 U.S. cancer doctors engaged in patient care, fewer than 5,000 reported any Part B drug billing in the CMS data set, of whom we estimate just 108 reaped 10 percent of total drug profits. It’s hard to understand the shape of the income distribution curve across all of these doctors – some may be the “biller of record” for colleagues in their practice, and others may infuse some or all of their Medicare fee-for-service patients at academic or hospital-based centers instead of in their offices– without more granular patient- and practice-level data across a wider set of payers.

Adding to the complexity, it’s also likely that only a minority of oncologists personally realize the profits they generate from Part B. Similar to other specialties, only about 40 percent of oncologists reported working in physician-owned practices in 2015. The rest, who work in academia or practices owned by hospitals or health systems, are typically paid a base salary and a bonus based mainly on patient care volume, with strictly financial factors (like drug mark-ups) contributing relatively little to their variable compensation. So in many practices, Part B profits are earned by corporate and institutional owners, and their impact on individual physicians is minimal and indirect.

On balance, it’s impossible to assess from public data how much oncologists’ opposition to Part B reimbursement changes is motivated by economic self-interest versus clinical factors. Doctors and professional groups could boost their credibility in this debate by helping collect, analyze, and disclose far more complete and granular data on practice volumes, patient demographics, payer mix, compensation models, and net profits from Part B than they have to this point. Until then, cancer doctors who object to reimbursement reform may continue, rightly or wrongly, to be viewed as “Medicus economicus” until proven otherwise.

Methods: We downloaded the Physician and Other Supplier Public Use File (PUF) for calendar year 2014 from the CMS website, which contains Part B data for fee-for-service Medicare beneficiaries. We identified doctors classified as “Hematology/Oncology”, “Medical Oncology”, or “Gynecological/Oncology” (N=7,765), and analyzed the 4,658 who billed drug services under Part B. For each physician, we calculated Part B profit (i.e., excluding ASP) by multiplying total Part B drug billing by (0.043/1.043). (Although the current formula defines the mark-up as 6% above ASP, the effective percentage under the budget sequester is 4.3%.) Descriptive statistics were calculated in Excel.

About the authors: Frank S. David, MD, PhD, is the founder and managing director of Pharmagellan, a biotech consultancy. He tweets about the drug and device industries, health care policy, and related issues at @Frank_S_David<>, and blogs at the Pharmagellan website and at Forbes.com. Andrew Matthews, MD, and Keshia Maughn, MPH, are an associate consultant and data scientist, respectively, at Pharmagellan

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A Real (Living, Breathing) Health Care Reform Plan

Dear Washington,

Congratulations! You have listened to the AMA and practicing physicians and made it a little easier to comply (at first) with the Medicare Quality Payment Program, part of the massive MACRA “pay for value” law. 

But CMS’ announcements in The Federal Register and “fact sheet” are incomprehensible gobbledygook that will be understood by neither doctors, patients, nor the rest of society. The language personifies the complexity, unwieldiness and confused thinking in this huge national policy. 

MACRA is a $15 billion boondoggle that the best research shows will neither improve quality nor control costs. Paying doctors for quality (e.g., doing a blood pressure exam) or efficiency may make sense theoretically, but it doesn’t work. Rather than making a dent in the continuing upward spiral of healthcare costs in America, it can even result in some doctors avoiding sicker patients because it affects their quality scores and income.

Early, poorly designed research suggested that paying for health or cost savings was effective, but these research designs did not account for already occurring improvements in medical practice that the policymakers took credit for. Decades of stronger, well-controlled research debunked these early findings and conclusively showed no effects of these economic policies.

So why does the Congress and administration continue to press ahead with this same tired and impotent policy?

Most importantly, a large cadre of influential economists have convinced the government that money is the only driver of quality and efficiency. Nothing could be further from the truth. Many factors affect measures of quality and cost savings. These include:

Social problems and lack of supports are root causes of poor health outcomes. These include poverty, language barriers, spousal abuse, drug abuse, rurality, early manifestations of dementia and many more. These factors are usually not measured by Medicare. 

Further, doctors do not prescribe antibiotic medications to patients who are allergic to them even if they are promoted in a quality measure. Similarly, after the ACA required CMS to penalize hospitals for hospital-acquired infections, studies showed that some doctors were simply altering codes to make it appear that the patient was admitted with the infection. When a better CDC dataset was used instead of “doctored” Medicare claims, this study showed no effect of the penalties on infection rates. 

In addition, as Uwe Reinhardt said, “the idea that everyone’s professionalism and goodwill has to be bought with tips is bizarre.” Why should Doctors only respond to financial incentives when thousands of studies have shown that opinion leaders, knowledge, clinical skills, patient demands and many other non-monetary factors all influence quality of care?

Perhaps the biggest reason for this giant boondoggle is the unflinching confidence in economic theories and models that lack a shred of evidence. Even pay-for-value and alternative quality contract policies lack any evidence that support programs like MACRA. In fact, we now have several large studies of accountable care organizations (ACOs) published in top medical journals that celebrate an inconsequential savings of about 1% without even considering (or measuring) that healthcare delivery systems spend much more than this in ACO operational costs; thus, the MACRA-Like ACOs actually lose money on a societal basis.

Currently, we are abusing primary care doctors on the front line with dozens of bureaucratic penalties and regulatory policies aimed at improving their performance.  

It is time to confront the reality of our abysmal, incomprehensible and inefficient healthcare system that charges far too much to our patients and society at large. It is time to move towards a simpler system that nevertheless embraces certain free-market principles because a single payer plan (“Communist medicine”) is not in the political cards. But we can reduce our healthcare expenditures by almost half by adopting any one of several European health plans that retain an insurance industry, guarantees access to all citizens to see any physician (e.g., in Germany), and totally eliminates high deductible health plans (e.g., those in the ACA) that can delay essential care and cause adverse health effects among low income diabetic patients. The savings are due to fair, negotiated price schedules that are more ethical than widely varying prices in the United States that are sometimes the result of large medical systems with market power determining higher prices than those of smaller institutions. 

We spend about one-fifth of our gross domestic product on medical care. If anything, this cost is accelerating since 2000. It is time to stop the nitpicking, band-aid regulatory policies that are driving doctors crazy without reducing costs or improving quality. It is essential to work towards the achievement of a new system of care that covers the entire population and costs less. Neither The ACA nor any Republican plan can accomplish this worthwhile goal.

Stephen Soumerai is Professor of Population Medicine and teaches research methods at Harvard Medical School.

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Death and Medicaid

By ANISH KOKA, MD

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I remember 7 South at the Children’s hospital very well. I remember the distinctive smell, the large rooms, the friendly nurses, and Shantel. For a brief period of time, Shantel and her little boy – a too skinny child named James – were there every time I was there with my little girl. 7 South was the GI floor – Shantel and I were there because our children had the same dastardly liver disease that, for the time being, was winning. And that was it. We had nothing else in common.

She grew up in North Philadelphia, not far from where I was finishing a residency program in Internal Medicine. She had three other children, was a single mother, and in the year that I spent shuttling to the hospital I never saw the father of her child. Shantel did not work, and relied almost exclusively on the welfare programs to make life work.

I was a medical resident, our family had a combined income north of $150,000/ year, and our health insurance was through my employer. My wife and I worked, which meant that we had the flexibility for one of us to stop working, and still maintain our benefits.

Shantel, I am sure, did not have such luxuries. Regardless, it is one of the beautiful things about America that James had the same opportunity at life as my child – their hospital room was no different than mine, their doctors were my doctors, the medications prescribed were the same, and access to a liver transplant list was determined by medical need, not the size of one’s bank account. Walking through the hospital doors in America is like going through a magic portal – contrast this to the resource limited developing world, where families frequently need to bring the medications their family needs to the hospital to be administered.

Much of the debate now about Medicaid cuts is ostensibly about James and Shantel. The debate as it is carried out, (by serious people!), is more Hulk Hogan vs the Machoman Randy Savage than it is Ali/Frazier. The analysts on television and social media would seem more interesting in marshaling outrage than actually discussing how best to care for those who have not. At the moment, the left finds itself under siege from the right, hungry to roll back the federal expansion of the last 8 years, and in their defense have rolled out the really big gun – science. The experts from the most hallowed sites in the land now claim that any attempt to reform medicaid amounts to a death sentence for Americans.

It is important to note that none of the experts speaking out against Medicaid reform identify themselves as partisans.  They  cloak themselves in evidence, and speak not about theories or possibilities, but the certainty of what they know based on science.  In this case, in order to argue for an expanded role for government in delivering healthcare, the left finds its most powerful argument to center around the lives saved by health insurance and the lives lost without a mechanism to deliver health insurance.

Does health insurance save lives?

A timely editorial summarizing the evidence related to health insurance recently appeared in the widely acknowledged bible of medicine – the New England Journal of Medicine – to ‘inform’ the debate on public policy.  The authors are distinguished, well- recognized names from the Harvard community that go on to discuss a large body of research that they have largely helpfully, and impressively generated.

The problem with connecting insurance and mortality is that it is incredibly hard to prove causation.  The vast majority of studies on this topic and all topics are observational studies because that comprises the vast amount of data that currently exists.  The problem, of course, is that the uninsured patient population is a very distinct population from insured patients.  Any analyses require accounting for confounding variables using self reported behavior, health status, and socioeconomic variables.  This still leaves omitted variables that are either unknown or unmeasurable, and perhaps hardest of all remains susceptible to reverse causality.  It is entirely possible, that underlying health status drives the choice to have health insurance.  Thus, it is entirely possibly that the claim that good health results from insurance may be like saying wind results from windmills.  This is an incredibly vexing problem for those shaping to move public policy with evidence which has the approximate value of adulterated bullshit.  A level up from parsing large observational trials is what’s called quasi-experimental studies, where health insurance status is unrelated to the choices patients make.  Medicare came into being in 1965 and bestowed insurance on Americans once they were 65.  If health insurance results in lives saved, one would expect mortality rates in the Medicare covered over 65 population to go down relative to the under 65 population.  It doesn’t. As seen in this visually compelling figure from Finkelstein & Mcknight in 2005, the institution of Medicare in 1965 had no impact on mortality.

If only we had data in this space where uninsured patients were randomly assigned via a lottery to receive insurance.  Remarkably, this happened in Oregon in 2008 when Medicaid expansion was decided based on a random lottery.  Oregonians who were able bodied, and uninsured and whose household income was less than 100% of the Federal Poverty level had to enroll in a lottery if they wanted health insurance.  A study of 12,000 patients over 2 years demonstrated no difference in multiple surrogate measures of health such as blood pressure, cholesterol or diabetes control.  Predictably, the expert analysis of the data had much to do with your prior belief in the role government should play in health insurance.  Those that believe health care is a right to be insured by the government focused on the limitations of the study, while conservative analysts accepted the natural conclusion that health insurance had little to do with positive health outcomes.  Undeterred by this data, and seeking to go beyond the limitations of the small size of the Oregon study, Sommers and Co. (author of the NEJM review) proceeded to do a quasi-experimental study of three Medicaid expansion states.  Sommers et al., use a difference in difference analysis – a statistical tool used to mimic a randomized control trial and account for comparing populations that don’t have the same starting point.  I can’t pretend to understand the various methods used in the analysis, but the results of this larger quasi-experimental study suggests medicaid expansion in the 3 states resulted in lower mortality.  As a way to provide plausibility for the reduction in mortality, a helpful graph is provided that looks at one of the conditions ‘amenable’ to medical care – HIV mortality.

HIV mortality does seem to decrease markedly in expansion states, ostensibly due to the expanded availability of antiretrovirals – but interestingly, the mortality reduction in this case seems to be decreasing significantly prior to medicaid expansion.  So the only hard conclusion to come to about Medicaid and mortality is that nothing is certain.  This doesn’t keep Dr. Sommers from taking to the pages of USA Today to use his ‘iron clad’ evidence to balance the ‘political rhetoric’ that insurance may not save lives.  And so it is that the randomized control trial evidence is dismissed, and minimized by the proponents of Medicaid.  The summary of evidence provided by Dr. Sommers in the NEJM refers to the only randomized control trial data as ‘highly imprecise data unable to rule out a mortality increase or decrease’.  It is ironic that the a high priests of evidence takes a position with this level of evidence – I can’t imagine Sommers and company would be willing to approve a drug that was unable to show a mortality difference in a 12,000 patient randomized control trial, and had conflicted observational/quasi-experimental data.  The casualty in this speculative endeavor where overreach reigns is is the credibility of the science of health care policy and its practitioners.

The funny thing is that I frequently take a stand with experts against what I find to be a selective interpretation of data.  I find it dangerous to ignore experts in their field solely because their expertise creates implicit bias.  I would be willing, and have been in the past, to give the coterie of experts in public health their due if it wasn’t for the fact that their expertise is applying statistics to big data, and not actually taking care of patients.  The onus is not on me to find the fundamental flaw in their work – it is for them to convince clinicians whose charge it is to actually manage health conditions that Medicaid as it is currently designed would improve hard patient outcomes.  From my vantage point, I have a difficult time understanding how Medicaid in its current form improves hard outcomes with chronic care management as has been suggested.  Mr. Garfinkel has refused to stop smoking for the four years I have known him, takes his aspirin when he feels like it, and does not like how his blood pressure medication makes him feel.  His only visits to me relate to acute illnesses, and he sees me because my wait time for urgent appointment is same day rather than the 3 weeks his primary care physician gives him.  Mr. Ramos is currently in the hospital with a bleed in his brain from uncontrolled hypertension.  I counted ten no-shows over the course of the last year.  It is true I could have done more, it is possible I could have tried to remotely manage Mr. Ramos’s blood pressure.  With a Medicaid plan that pays between $30 – $40, even non-profit medical centers that charge $1000 for a bag of saline shy away from Medicaid patients – how could physician practices do better?

Thus, it comes as no surprise to me that mortality is a heavy lift that is probably too heavy for insurance to bear, and I need a lot more than quasi-experimental data to change my mind.  There is some value to health insurance – patients are happier, and have protection from medical bankruptcies- but is that worth the $550 billion dollars we spent on Medicaid in 2015?

Medicaid can and should be better, but at the moment I see no plans to reform Medicaid that would help the physicians charged with taking care of this population.  If public health policy experts are actually concerned about chronic care that may work to avoid some of the 40% of Medicaid dollars spent in hospitals, and give doctors a shot at improving outcomes that matter, it may help to resource physicians on the front lines better.  The Healthy Indiana Plan, set up by the current CMS administrator, Seema Verma, used tobacco tax dollars to raise medicaid rates to equal medicare rates.  While this is a promising start that at least tries to solve the challenge Medicaid patients face when trying to access elective care, it could go much further.  Allow Medicaid patients to use federally funded HSA’s to pay physicians a monthly subscription of as little as $50-$100/month, which would make actual major strides towards the ambulatory care of medicaid patients.

The truth is that I’m an optimist when it comes to Medicaid.  At the moment, the federal government matches 51% for every dollar spent by the states on Medicaid patients with no cap.  Driven primarily by Medicaid expansion, national health expenditures that had been flat relative to GDP prior to 2014, started to rise again.  This is an unsustainable path.

Medicaid can and should be better, but at the moment I see no plans to reform Medicaid that would help the physicians charged with taking care of this population.  If public health policy experts are actually concerned about chronic care that may work to avoid some of the 40% of Medicaid dollars spent in hospitals, and give doctors a shot at improving outcomes that matter, it may help to resource physicians on the front lines better.  The Healthy Indiana Plan, set up by the current CMS administrator, Seema Verma, used tobacco tax dollars to raise medicaid rates to equal medicare rates.  While this is a promising start that at least tries to solve the challenge Medicaid patients face when trying to access elective care, it could go much further.  Allow Medicaid patients to use federally funded HSA’s to pay physicians a monthly subscription of as little as $50-$100/month, which would make actual major strides towards the ambulatory care of medicaid patients.

The truth is that I’m an optimist when it comes to Medicaid.  At the moment, the federal government matches 51% for every dollar spent by the states on Medicaid patients with no cap.  Driven primarily by Medicaid expansion, national health expenditures that had been flat relative to GDP prior to 2014, started to rise again.  This is an unsustainable path.

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If Your Premiums Go Down but Coverage Gets Worse, Does Your Healthcare Matter?

By JASON CHUNG

Picture this. Amy becomes pregnant while working as a high school teacher. Her employer’s health insurance plan pays bill was covers the maternity bills and she happily raises her twins.

Fast-forward a few years. She’s decided to become an entrepreneur and runs a small business. She becomes pregnant again but, this time, finds that her $400 a month individual health insurance policy won’t cover the expenses. In fine print, she discovers that she needed to purchase a special rider to activate maternity care benefits. She’ll have to pay $10,000+ out of pocket now, putting her burgeoning business at risk.

Angry at this, Amy decides to switch insurers but, to her dismay, she finds that the four largest insurers in her area don’t cover most expenses associated with a normal delivery. Amy has nowhere to go. Also, since pregnancy is a pre-existing condition, Amy is advised by her doctor to “not become pregnant again” if she wants to get quote reasonable health insurance rates during her search.

This is not an exaggerated or dystopian situation, it’s a real example from 2010.

It highlights the Russian roulette-style approach to healthcare coverage which existed prior to the introduction of Essential Health Benefits (EHBs) mandated by the Affordable Care Act (ACA).

Contrary to many hyperbolic, and tacky, bill titles in Washington like “The Reducing Barack Obama’s Unsustainable Deficit Act” or the “Big Oil Welfare Repeal Act”, EHB is a relatively subdued term describing what many Americans would consider to be crucial in a healthcare plan. The ACA’s EHBs ensure that all Marketplace plans and coverage via the ACA’s Medicaid expansion includes the following services:

  • Ambulatory patient services
  • Emergency services
  • Hospitalization
  • Pregnancy, maternity, and newborn care
  • Mental health and substance use disorder services
  • Prescription drugs
  • Rehabilitative and habilitative services and devices
  • Laboratory services
  • Preventive and wellness services and chronic disease management
  • Pediatric services, including oral and vision care
  • It also ensures that key benefits for women including birth control and breastfeeding are included.

With the proposed elimination of EHBs in Medicaid in their draft healthcare bill, Senate Republicans have joined their House counterparts in creating a likely “tree falling in the woods” philosophical conundrum – if health coverage covers little, do low premiums actually mean anything?

Cost vs. Quality

The establishment of EHBs represents not only a signature achievement of the ACA but it offers a window into the entire philosophical debate currently raging regarding what health care coverage should mean in the United States. Namely, what is more important – cutting costs for individuals or promoting the proliferation of quality services?

By bundling EHB services, healthcare premiums generally do go up in the aggregate. A recent Milliman actuarial study took the example of mandated coverage for prenatal/delivery benefits and found that there would be an across-the-board increase of $8 to $14 in health insurance premiums in a single risk pool. EHBs are partially why the general trend has been that premiums and deductibles have been going up for many American families.

Yet, it is also true that Americans get much more for their premiums and deductibles. EHBs represent a significant and robust floor for the breadth and quality of services that Americans can expect with their health insurance. Healthcare consumers also get a measure of predictability in what and how much their coverage plans will cover and bans on annual and lifetime limits on EHBs further help prevent the most catastrophic economic outcome – medical debt leading to personal bankruptcy filings. After all, as Lois Lupica of the University of Maine School of Law notes, “[i]f you’re uninsured or underinsured, you can run up a huge debt in a short period of time.

House vs. Senate Republicans

The rhetoric of House Republicans suggests that their primary motivation rests in lowering premiums and their plan of slashing EHBs for all – outlined by s. 121(c) of H.R. 1275 (hyperbolically titled “World’s Greatest Healthcare Plan of 2017”) – would likely do that. But it would do so by returning to a system where many insurance plans are “skimpy” and leave Americans on the hook for services not covered. Certain services would also become more expensive simply due to the contraction of pools from which to distribute costs. The segmenting of pools means that certain groups could simply choose not to help pay for services affecting other groups – such as men opting out of plans that cover maternity care.

Eliminating EHBs would have knock-on effects for everyone. Millions of Americans could suddenly find that their individual or small group plans no longer cover critical services such as prescription drugs or emergency room visits. Even Americans working for larger employers wouldn’t be immune from pressures as employers could once again cap reimbursements for current EHB services.

Based on their respective draft bills, Senate Republicans seem to have a better handle on the problems that this might cause – which is why they left the potential ability to weaken EHB definitions and protections to the states. Having a blanket provision explicitly repealing EHB federally would likely adversely impact many, many groups of Americans and, to quote the President, be unnecessarily mean. This is likely why Senate Republicans have chosen to restrict the explicit rollback of EHBs to those on Medicaid (per s. 126(b)) as they realize that low premiums may mean that Americans have difficulty accessing a decent range of services for their premiums – and they don’t want to be blamed for it.

Impact on the Poor

But where both House and Senate Republicans seem to agree is that the poor accessing Medicaid do not and should not have a right to quality coverage. Senate Republicans may have been slightly more parsimonious when it came time to repeal EHBs but their “Sunset” of required EHBs in Medicaid plans represents a public and cutthroat view of healthcare – that it is a privilege only for those capable of paying.

Ultimately, this is a value judgment – albeit an unforgiving one that may be out of touch with Americans based on recent polling. It may also lead to self-defeating spirals as poverty already may have negative, and socially expensive, long-term health impacts. With EHBs cut, access to a range of preventive, pediatric and managed care services critical to the welfare of lower-income Americans is jeopardized.

In light of such potential outcomes, Senate Republicans should recognize they will have difficulty in selling their healthcare bill as a pragmatic and principled plan – especially as long as “new entitlements” in the form of stabilization funding or repeals on taxes for already highly profitable (and unfairly legally protected) pharmaceutical and medical device companies continue to be pushed.

With income inequality already a hot button issue, Senate Republicans should be aware of the droves of American voters who find such handouts distasteful. If they survive in the final bill even as EHBs in Medicaid are clawed back, Republicans may find that distaste with their values and priorities to be a political – and generational – problem. After all, 2020 looms as the first general election where Millenials will outnumber Baby Boomers.

Jason Chung is currently senior researcher and attorney at NYU SPS Sports and Society, in New York. He tweets at @ChungSports.

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Healthcare’s Fake News Epidemic

By BRIAN JOONDEPH, MD

Fake news has replaced responsible journalism. It’s hard to know what to believe. It wasn’t long ago that supermarket tabloids like National Enquirer were considered fake news. Now it seems the Enquirer and TMZ may be more reliable sources of accurate news than the New York Times or Washington Post.

Government agencies aren’t immune from the fake news trend either. The Congressional Budget Office describes itself as, “Strictly nonpartisan; conducts objective, impartial analysis; and hires its employees solely on the basis of professional competence without regard to political affiliation.”

I’ll bet most newspapers and television news networks say the same about their own objectivity.

The CBO analyzed the American Health Care Act of 2017, a lame effort by Republicans to repeal and replace Obamacare.  Passed by the House, it’s now on to “the greatest deliberative body in the world.”

Here the Senate will dither and dawdle, and likely not pass anything. What about the election? What about Trump’s campaign promise to repeal and replace? Campaign promises are for chumps, after all. Congress has had years to repeal and replace Obamacare and has done nothing. Ditto on tax cuts, immigration reform, building a wall, and other campaign promises easily made but not kept.

Even Senate Majority Leader Mitch McConnell has thrown in the towel, saying, “I don’t know how we get to 50 votes at the moment.” He has 52 votes in his caucus, but perhaps it’s Common Core math leading him to conclude that 52 is less than 50. Senator Lindsay Graham joined the chorus of naysayers also saying no Obamacare repeal this year. Does the GOP establishment even want to repeal Obamacare? I wonder.

The CBO threw cold water on the House repeal effort claiming 23 million more would be uninsured by 2026 under AHCA compared to the status quo of Obamacare. This assumes that when the individual mandate disappears, the law requiring everyone to purchase health insurance whether or not they want or need it, no one will purchase insurance of any kind. Really?

If inexpensive catastrophic plans became available as an alternative to Obamacare, no one would buy them? That’s like saying if BMW went out of business, sales of other car brands would remain the same, not increase with BMW customers choosing Fords or Toyotas instead. Inexpensive catastrophic plans are ideal for many young healthy adults but are not available under the rules of Obamacare. They would, however, be purchased if priced reasonably. Just like with expensive cars.

A bit of positive news too from the ACHA which has not been reported. The CBO also predicted a $120 billion savings from the ACHA over the next 10 years, but this wasn’t deemed newsworthy by the media, burying this fact in the 18th paragraph of their stories.

Those wanting to maintain the status quo of Obamacare, such as California Senator Kamala Harris, doubled down on CBO projections saying “129 million people with preexisting conditions could be denied coverage.” How real is that number?

The Kaiser Family Foundation notes that 49 percent of Americans receive employer-based insurance, which covers preexisting conditions. Ditto for 20 percent on Medicaid and 14 percent on Medicare. Leaving only 16 percent on individual plans (Obamacare) or uninsured. The uninsured constitute 9 percent and preexisting conditions are moot as these individuals don’t have insurance anyway. Leaving 7 percent on Obamacare plans.

As an interesting aside, why are 9 percent of Americans still uninsured? I thought Obamacare was supposed to fix this?

Of the 7 percent on Obamacare plans, the good news for them is that the ACHA does require coverage for preexisting conditions. Even CNN concedes that point.

The devil, however, is in the details. Covering a condition doesn’t mean coverage for each and every available treatment option. Those with Obamacare policies already know this. Limited formularies. Many top hospitals and physicians out of network. Unaffordable copays and deductibles.

Your heart problem may be covered but the only hospitals and surgeons able to treat your particular problem are not in your insurance network.  Or the out-of-pocket portion is unaffordable. So you are technically covered for your preexisting condition but may not like or be able to afford the treatment options available to you. In other words, if you like your doctor you may not be able to keep your doctor.

The reality is that only 500,000 individuals are in potential danger of losing their preexisting coverage if Obamacare is repealed, according to a detailed analysis by Betsy McCaughey. All told, a drop in the bucket, but for the media, the sky is falling.

These half million individuals could easily be placed on Medicaid, covering their preexisting conditions with little out-of-pocket expense. Much smarter to attend to this small group rather than make a mess of the system for the remaining 99-plus percent.

Right now we only have a House bill. One of many small steps before grand pronouncements can be made about what replaces Obamacare. It’s not law, simply a bill. The Senate needs to pass their own bill, a long shot at this point. Then back to a House-Senate conference to reconcile the two different bills. Followed by another vote in both the House and Senate before it even gets to President Trump for signature and passage into law.

The media, by throwing out fake or exaggerated news as the legislative process has just gotten underway, undermines any realistic chance of dismantling Obamacare. Despite the fact that it is unaffordable for many and in its own death spiral.

It seems preserving Obama’s legacy is the media’s priority over thoughtful reporting and analysis. Expect the media to double down after Trump threw away one of the other Obama legacies, the Paris Climate Agreement. If the media continues to throw cold water on every repeal and replace effort from Congress, via fake news and fear-mongering, Congress will cower and eventually do nothing. Leading to the irony of Obama’s legacy being the ashes of Obamacare once it finally implodes.

Brian Joondeph is a writer and ophthalmologist based in Denver.

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