Oct
15

Someone please explain this…

If the medical device tax isn’t repealed, a few dozen Congresspeople are willing to default on our debt, potentially causing international financial turmoil and a major recession.

That’s reality, or at least what passes for reality these days.

Here’s the path we’ve trod to get to this point.

  1. A few dozen Congresspeople refused to pass a budget by October 1 because they wanted PPACA killed.  The Speaker of the House, averse to violating the “Hastert Rule”, went along with their demands.
  2. The Senate refused to comply, and anyway, the President would not have agreed.
  3. As public opinion turned increasingly against the few dozen, and their increasingly untenable position became increasingly obvious they changed their demands, from a delay to:
    • a delay of PPACA implementation, then
    • a repeal of the medical device tax, then
    • a delay of the enrollment mandate, then
    • a demand that Congresspeople and their staffers would have to pay all their premiums themselves; then
    • a delay of the employer reinsurance tax…
    • now PPACA appears to be off the table, and instead there’s a demand for some budget talks around addressing the sequester and long-term entitlement cuts.

Sure, some of these were mixed in together, and others were sorta kinda coupled, but you get the picture.

As some readers have pointed out, the Congresspeople’s actions are, in fact, legal.

They are also mystifying.  Sure, the most vocal come from very safe districts where their actions seem to reflect the current will of their voters, but is delaying the medical device tax really worth defaulting on the national debt – and the all-too-likely consequences of a default?

Medical device tax or… world-wide financial meltdown, immediate return to 2008 recession…

Of course, now that the GOP is on the run and desperate for a deal, any deal that allows them to declare victory (maybe changing PPACA’s health plan colors from bronze silver and gold to red, white, and blue?), Senate Majority Leader Reid is playing his own brinksmanship game, demanding a roll-back of the sequester.

The GOP won’t agree to that, so we’ll likely get just what we would have had if this whole stupid pointless embarrassing mess hadn’t even happened – a short-term deal late on October 16 (that’s tomorrow!) with some nice words about negotiations over long-term entitlement reform and revenue generation.

What does this mean for you?

Elections have consequences.


Oct
4

Status report: Obamacare implementation

Here’s where things are.

Briefly, my best guess is less than a hundred thousand folks have enrolled in insurance via the Exchanges so far.  That’s based on reports I’ve seen from several sources identified below.

And, there are a lot of health plans participating, with 2/3 of states offering 4 or more health plans, each with multiple benefit plans.

Not surprising, as Massachusetts’ experience with their “exchange’ indicates people accessed their system about 18 times before actually enrolling.

Those shopping for coverage are finding lots of options, as 2/3 of the states have four or more health plans selling thru the Exchanges, while eleven of the most populous states have ten or more plans participating.

Carrier Participation Map - Final

Of course, PPACA implementation started back in 2010, with the elimination of lifetime caps on medical expenses, extension of coverage to dependents up to age 26, increased reimbursement for primary care under Medicare and other interim actions.

What does this mean for you?

Not surprisingly, there’s far more shopping than buying, and a raft of technical and capacity problems on the Exchange servers.  As the tech issues get fixed, we’ll see more traffic and more enrollees, especially in late November.

Until then this will quickly become yesterday’s news.


Oct
3

Is killing Obamacare worth this?

A couple or three dozen Congresspeople – and the House Speaker – have shut down the federal government because they object to PPACA.  And the shutdown may well extend to a refusal to raise the debt ceiling.  The economic impact is significant:

  • The economy is losing $300 million a day.
  • A three-week shutdown will decrease GDP by almost 1%, this in an economy that has struggled to keep growth at 2%.
  • 2 million federal workers’ paychecks are delayed; 800,000 may never get paid.  They have mortgages, tuition payments, credit card bills to pay.

That’s the economic picture; the effects on individuals are diverse, but the longer this goes on, the more painful it will become.

I’d suggest there’s a longer-term problem, one that will have an unquantifiable but nevertheless profound negative impact on the US; the vilification of federal government employees by politicians and pundits who denigrate those workers and the work they do.

After three years of no raises, continued demonization by strident and powerful talking heads and politicians, after being told they are the problem, the morale of the average government employee has got to be pretty low.  These are the people who put out fires, keep airplanes from hitting each other, ensure our food is safe, pay our parent’s Social Security and Medicare bills, lock up bad guys, prevent Iran from funneling money to their nuclear program.

Sure, some are pretty unproductive, but most work hard, are proud of what they do, and do it well.  

I can’t see how the ongoing “they are the enemy” meme helps our country.  Sure, it makes for great theater, but who would want to take a job where you’re constantly told you are lazy, overpaid, feckless, and a leech?

I may be biased as I have quite a bit of experience with federal workers; my Dad was in the CIA and its predecessor organization for 25 years; my Mom worked for the Agency – and managed fingerprint files for the FBI during WW II. Both were very proud of the work they did, did it very well, and made a difference. My aunt was responsible for all Navy payroll for a decade; and woe to anyone who screwed up any of “her boys'” paychecks.  Other family members are in federal law enforcement, and I cannot begin to describe the sacrifice we have paid for that commitment.

It angers and saddens me to see and hear the derisive, uninformed, and flat out wrong comments by the Bachmans and Issas of the world.  But more importantly, it shows that they really don’t understand, or perhaps don’t care, that their grand-standing will do lasting, and real damage to our country.  

If we can’t attract hard-working, intelligent, competent people to work in public service, we’re screwed.

And we have no one to blame but ourselves.


Sep
30

Exchanges open tomorrow – what does this mean?

Come hell or high water – or even a government shutdown, the Exchanges are going to open tomorrow.  Here’s what it means.

  • Some will not be “fully operational” – Spanish language options won’t be on-line in Nevada for some weeks; Medicaid and subsidy eligibility can only be accessed via phone in some states; small businesses can’t buy coverage till November.
  • Estimates are that only about 7 percent of the population will obtain coverage thru the Exchanges – or about 23 million people.  The rest will be covered via Medicare, Medicaid, and employer plans, and other means.
  • The open enrollment period is six months; don’t expect all 23 million to sign up tomorrow, or even this time around.  This is especially true as enrollees have to pay their first month’s premium within 30 days of enrollment; I wouldn’t expect a lot of folks to sign up tomorrow and pay a month’s premium on coverage that won’t kick in for 90 days.
  • Coverage begins January 1, 2014.
  • By the end of the initial enrollment period an estimated 7 million will haver purchased coverage thru the Exchanges.

Sep
26

The irony of Ted Cruz

In Cruz’ 21 hour infomercial he read Dr. Seuss’ Green Eggs and Ham, ostensibly to his daughters.

Cruz would have been better served to learn Seuss’ lessons himself.

His fauxlibuster was ostensibly driven by his objection to health reform and desire to eliminate funding for PPACA. 

A.  that’s not going to happen.  and

B.  the author of Green Eggs and Ham was a major supporter of health research and reform

Cruz’ choice of Suess books heaps irony on irony; Green Eggs and Ham is about trying new things, being open-minded, embracing change.

And the real Dr Seuss, Ted Geisel, was not only an unabashed liberal, he and his wife were major supporters of health research and reform.  

Dartmouth College’s medical school – now named for the couple, is a leading force in understanding health care and developing both clinical and management solutions.

“The Audrey and Theodor Geisel School of Medicine at Dartmouth strives to improve the lives of the people it serves—students, patients, and local and global communities—and to live out the Dartmouth ethos that “the world’s troubles are your troubles.”

The School includes the Dartmouth Institute for Health Policy and Clinical Practice and the first center to comprehensively examine variations in health care costs in U.S. medical practice (The Dartmouth Atlas).

Let’s hope Cruz’ daughters take a lesson from Suess, and not from dad.

 


Sep
23

Why Obamacare is truly terrifying

The actions of some of Obamacare’s opponents are outrageous, immoral, abhorrent, revolting.  And very revealing.

The latest plunge into the cesspool is courtesy of the Koch Brothers; if you haven’t seen Creepy Uncle Same, don’t. You’ve been warned.

The disgusting ad is the latest in a series of outright lies and complete fabrications perpetrated by Koch and their fellow cesspool-dwellers on the wingnut right.  Amazingly, some of their pundits seem to think this is acceptable behavior, that using a video of Uncle Sam preparing to rape a young woman is funny, appropriate, acceptable.

It is not, absolutely not.

Leave aside the minor matter that the ad is complete bullshit, and the pathological minds that would fund, create, applaud such an ad are pathetically twisted people.

Instead, ask yourself why they’d descend to such depths in an attempt to scare young people away from enrolling in health insurance.

First, it’s just stupid.  Of course everyone should have health insurance.

Second, it goes directly against a fundamental conservative principle – personal responsibility.  If young immortals don’t have insurance – for whatever reason – when they get sick or hurt you and I end up paying for them.  That’s wrong.

Third, if Obamacare/PPACA is so bad, so fundamentally flawed, so bound to fail, why do opponents have to resort to rape scares? After all, it is based on principles laid out by the Heritage Foundation, a central pillar of the conservative movement.

And therein lies the core issue.  I posit the following.

For reasons we’ve discussed here at great length, PPACA won’t “fail”, simply because it fixes the core problem with the current insurance market – Private insurers will not insure people who are likely to have health problems at anything close to affordable rates.  And they shouldn’t. The “solutions” proposed by opponents are just laughable. The basic elements of the GOP’s approach – buying insurance across state lines, tort reform, meaningless tax credits, a paltry high-risk insurance pool – do nothing to address that core problem.

When it does succeed, it will blow a very large hole in what passes for current ultra-conservative theology; government is completely incompetent.

That scares the pants off Koch and their allies, the fear that personal experiences with a government-run program will be generally pretty positive; that things will work pretty well.

Oh, the horrors.

The young woman in Koch’s Creepy ad is a metaphor for the brothers’ own reaction to Obamacare; it is going to work pretty well, people will like it, and they will then become more favorably disposed to more activist public policy.

 


Sep
11

Health insurance costs under PPACA…not what you’ve heard

There’s been a lot of yelling about insurance costs under PPACA/Obamacare of late, most of which is uninformed, unintelligible, ideologically based or just plain wrong.

Here’s the scoop.

As of 8/30, 17 states and DC have released comprehensive rates for insurance plans bought via their Exchanges. And the news is quite good.

The CBO’s  projected rates for a  40 year old individual were $320; the benchmark rates in 15 of 18 states out so far are lower than CBO projection.  Benchmark rates are based on the second lowest priced Silver plan.  The two highest cost states – VT and NY – are anomalies as the rates and plans are affected by current rate limits and the existing ban on medical underwriting, both of which drove rates up.

Because the actual premiums are lower than projections, the federal budgetary cost of subsidies is actually going to be lower than projected.  This assessment is based on a comprehensive analysis done by the good folk at Kaiser Family Foundation did a comprehensive analysis.

If a 40 year old individual with income at 250% of the FPL uses tax subsidy to buy a bronze plan, insured’s rate can be as low as $97 in Hartford CT.

So what accounts for the differences in today’s premiums vs ACA premiums?

Rates are higher than today’s because:

–       pre-existing conditions will be covered under ACA will increase premiums

–       coverage is more comprehensive; for many people, their coverage will improve; todays plans often have (much) higher deductibles, limits on specific types of services,

–       limits on cost variation by age, medical underwriting, and gender rating

Rates are lower than projected because:

–       80/20 MLR threshold lowers premiums (insurers have to pay at least 80% of premiums for actual health services

–       rate review by states/feds will reduce premiums; in some states it already as as the local regulators have required insurers to cut premiums to earn a place in the Exchanges

–       federal reinsurance for high risk members will lower premiums

–       most purchasers will get subsidies, either via credits based on their income (declining subsidies based on income from 100% to 400% of the federal poverty level) or credits for small employers.

–       Most importantly, and I’d argue most significantly over the long term, PPACA’s Exchanges will engender fierce price competition, price competition that doesn’t occur today because consumers don’t know what their cost will be until they’ve completed the underwriting process.  In the Exchanges, they’ll be able to directly and quickly compare plans from multiple insurers, without having to wade thru the minutia of different benefit designs, coverage limits, and exclusions and limitations.

Notably, in Oregon, two insurers’ plan costs came in high; the insurers realized they were priced out of the market and reduced their premiums to compete – this is very different from today where medical underwriting and the application process hides actual prices.

What does this mean for you?

Perhaps the biggest benefit of PPACA’s Exchanges is they level the playing field, making it easy for consumers to figure out what their costs will be for which plans.  This is going to force insurers to compete based on value, not on how well they can underwrite – aka avoid selling insurance to anyone who might actually have a claim.

 

 


Aug
1

Lousy back pain care – it’s not just work comp

What’s changed in treating back pain over the last decade?

More narcotics and fewer NSAIDs.  More referrals to specialists, less treatment by primary care docs.  More MRIs and CTs.  

A really illuminating article just published in JAMA provided those insights and more, concluding “Despite numerous published clinical guidelines, management of back pain has relied increasingly on guideline discordant care.”

Like 29% of patients prescribed narcotics.

In other words, more care, delivered by more expensive providers, with higher risks, despite no evidence it improves results.

Not only do we have a looooong way to go, it’s getting longer every day…

 


Jul
31

Ideological blinders, work comp, and Obamacare – part 9 of 9

We can all agree on something – No one – and I mean NO ONE – thinks PPACA aka Obamacare is the perfect solution to the health care insurance, cost, and quality mess.

Liberals decry it for the failure to offer a public option, if not a single payer.

Conservatives hate it because it represents what they see as a big intrusion into private decision making process.  The fact that PPACA closely resembles former Republican Senator Bob Dole’s plan, and one advanced by the neo-uber-right Heritage Foundation just a couple decades back isn’t enough to overcome that “negative feeling”.

Let it go, folks.

The reality is, PPACA is going to be a reality.  You can either continue to complain, or start figuring out what to do about it.  Here are a few things it would behoove any workers’ comp payer or stakeholder to get done.

  1. Get much, much closer to key providers to ensure your claimants can get access to surgery, primary care, PT and the like.
  2. Watch for changes in billing practices by hospitals who are looking to adapt to reduced Medicare reimbursement.  Expect higher prices and more services.
  3. Watch for physician practices billing as facilities, with all the additional cost inherent due to fee schedule anomalies.
  4. Monitor drug prices; as more people get coverage, manufacturers may decide they can raise prices a tad.  It happened after Part D, and it may well happen again.
  5. Add “health insurance coverage status” and the name and policy number of the insurance plan to your FNOI process; that way, if you have to pay to treat non-occ conditions, you know who to send the bill to.  As well you should.

There’s a lot of potential side effects, many of which we won’t see until several years out.  The key is to look for them, and blinders will restrict your vision such that you won’t be able to adapt and maybe even take advantages of positive side effects.

What does this mean for you?

Rewards await those who see broadly and clearly.

 


Jul
29

Obamacare and workers’ comp – part 7 of 9

Last week we briefly discussed a few ways PPACA may affect quality of care; this morning it’s a bit about outcomes research.

To see what this has to do with comp, skip to the last couple paragraphs below.

PPACA aka Obamacare funded the Patient-Centered Outcomes Research Institute, which focuses on research intended to help individuals determine what care is best for them, what they can do to improve their outcomes, and what they can expect given their health condition and treatment choices.  (details are here). The idea is pretty basic; to quote Sy Syms, “an educated consumer is our best customer.”  Patients who know their health conditions, understand their treatment options and the pros and cons of those options, and are able to discuss those options with their providers are going to get better care and better outcomes – defined as what is best for them as an individual.

If an individual understands the risks and potential implications of treatment options, then that individual can make the best decision – defined as what’s best for that individual.  As an extreme example, I may choose a risky and painful course of chemotherapy to treat my cancer, while you may decide that’s not for you. 

In actuality, there were a lot more funds in the Recovery Bill (remember the 2009 bill?) known as ARRA than in PPACA.  While most of that legislation was in the form of tax reductions, there was some spending on health care; specific to our discussion $1.1 billion was allocated to health research. This was split between three agencies;  $300 million to Agency for Healthcare Research and Quality, $400 million to NIH, and $400 million for HHS itself. The money has been allocated to several areas; data infrastructure, evidence generation, evidence synthesis, research and evaluation, implementation and others.  (a detailed discussion is here.

All of NIH’s and most of AHRQ’s dollars were invested in comparative effectiveness research (CER), evidence generation and translating and disseminating the findings.

Simply put, CER assesses “which interventions are most effective for which patients under specific circumstances.” NIH is looking into health care for seniors, diabetes prevention follow-up care, schizophrenia, breast imaging, chronic kidney disease, and many other conditions.

AHRQ’s work identified key gaps in evidence, found researchers qualified to fill those gaps, and funded their research. It’s hard to overstate the importance of this work; there is precious little consensus around treatment for many conditions, with wide geographic variation in treatment patterns.  The Clinical and Health Outcomes Initiative in Comparative Effectiveness (CHOICE) focuses on pragmatic research; what actually works, in real-world clinical settings.  There’s also a registry of diseases and specific medical tests, devices, and surgical procedures intended to track long-term outcomes and the viability of devices.

So, what does this have to do with workers’ comp?

There are direct and indirect impacts – for example; one of the projects funded by PCORI focused on “Long Term Outcomes of Lumbar Epidural Steroid Injections for Spinal Stenosis”; a procedure far too common in worker’s comp (if not for stenosis specifically).  Another focuses on improving primary care for back pain, a third on non-surgical treatment methods for lumbar spinal stenosis, a fourth addresses obesity care in a primary setting, a fifth evaluates the best ways to disseminate outcomes research, a sixth looks at quality metrics for medical rehab, a seventh focuses on psycho-social treatment for chronic pain…

Given the oft-heard complaints – entirely appropriate complaints – from work comp professionals about the wide variation in quality of care, over-use of surgery, inability to manage chronic pain, impact of obesity, and generally crappy medical care delivered to far too many injured workers, there’s no question the funds from PPACA and ARRA will greatly benefit work comp.

As a side note, we spend about $2.6 trillion a year on medical care in the US, and less than one-tenth of one percent of that amount on objective research to figure out what works and what doesn’t.

Is it any surprise US health care is so wasteful and screwed up?