The Type of Consumerism Healthcare Really Needs

By Sachin H. Jain
Forbes, April 17, 2018

For decades, many have been dreaming of a revolution in healthcare based on the premise that making patients more accountable for healthcare costs—making them “consumers”—will result in higher quality and lower costs. It’s a brilliant vision. And smart people believe it makes sense. Except for one little detail: For many patients, it’s not a dream, it’s a nightmare.

Misplaced Conventional Wisdom

There is a conventional wisdom about patients that is inconsistent with the reality that many patients live. It starts with the premise that patients want to shop for healthcare like they shop for other goods and services. We assume patients want to go on-line and manage their health and make all of their own healthcare decisions. We assume they want to use rating ranking sites to make decisions about where to get their primary care and medicines. We assume they want to shop like it’s Black Friday.

The conventional wisdom continues with assumptions about the literacy, engagement, capability, and wealth. For many healthcare entrepreneurs, the median patient is assumed to be an MBA graduate with significant disposable income. The imagined patient has a “Type A” personality and wants to be obsessively engaged in every aspect of their health or healthcare.

And, on a related note, the conventional wisdom assumes high levels of digital literacy. The average patient has a sophisticated smartphone and multiple paired Bluetooth devices and knows how to use them. And would be able to improve their health if they just had the right tools to do so.

The implementation of this view is the proliferation of point solutions that aim to solve problems that we assume that patients prioritize: transparency of lab data, access to on-line medical records and easy access to appointment scheduling. While these are wonderful convenience features that we should undoubtedly adopt, they do very little to fundamentally change the healthcare cost or quality for consumers.

And they’re oddly implemented as an endless maze of disconnected portals, tools, and apps—few of which speak to each other and few of which delivers anything close to the value that we believe that they will. Either because patients don’t use them as intended, or they fail to capture the complexity of the broader ecosystem in which our patients live.

Masked Incrementalism

And there are many companies and startups that excite the people that are built on this vision of consumerism with clever tag lines that mask the incrementalism that underlies them. These are healthcare solutions that are really good for the 80% of patients who account for 20% of our healthcare costs. But the question is whether this perspective on the empowered consumer works for the 20% of patients who account for 80% of the costs.

Because if you are really trying to change the cost or quality equation in healthcare—you need to imagine a different consumer profile. One where the patient doesn’t want to be engaged in the traditional sense of the term—but where everything just works right for the patient. Where needs are anticipated and addressed before the patient or family can articulate them. One where we push beyond the superficial causes for problems—and dig far deeper into their root causes.

A Different View of Consumerism

CareMore, the company I lead, espouses a very different vision of consumerism. By way of introduction CareMore is a $1.4B Medicare and Medicaid delivery system that focuses on the care of more than 150,000 high-cost, high-need and vulnerable patients in 10 states. Our mission is to make health care more accessible, affordable and simple for the patients we are privileged to serve.

CareMore’s View

CareMore’s view of consumerism is grounded in the following simple ideas: 1) Healthcare should anticipate and deliver on consumers’ needs proactively. 2) Sick people should not have to shop for the care they need. 3) Consumers should not pay out of pocket for the things that they need.

Sick Patients Shouldn’t Have to Shop

Probably most controversial notion is the idea that sick people shouldn’t shop. But think about it. You’ve just been diagnosed with breast cancer. Multiple sclerosis. Diabetes. Do you want to be flipping through directories to find a doctor? Or do you want the appointment to be set up for you urgently with exactly the right specialists for your condition? Do you want the right durable medical equipment needed for your delivery to just show up or do you want to look through a website to pick your equipment? While I recognize there are a number of consumers—who given the opportunity to make these choices, would want to be in the driver seat—I would argue that most would not. They would want, most simply to just be cared for.

There is poverty in thought and intellectual laziness when we simply say consumers want to make these decisions.

https://www.forbes.com…

In this article, Sachin Jain presents the fallacy of consumer-directed health care, that somehow the patient has the desire to use their own expertise and control of their own funds to shop for the best care available and in doing so will improve the quality and reduce the costs of health care. Jain explains that, instead, patients do not want to shop for their health care but would prefer that beneficial care be offered proactively without financial barriers that impair access to that care.

In other words, patients want the health care they need when they need it without having to shop in a complex health care environment in which they have little or no expertise. This is an argument for supporting a robust and efficient primary care infrastructure. Such a system should provide easy entry to appropriate technological and specialized services for patients with medical needs, not to mention being a source of preventive services.

It should be noted that the conclusion presented by the author, but not included in the excerpts above, is quite biased. Sachin Jain, MD, MBA is President and CEO of CareMore Health, a subsidiary of Anthem that provides Medicare Advantage and Medicaid managed care plans. Rather than framing the solution as primary care, in the rest of the article he essentially is marketing their private Medicare and Medicaid plans.

Although many of us at PNHP support integrating health care through a primary care infrastructure, we remain opposed to private Medicare Advantage and Medicaid managed care plans, especially those offered through a for-profit Wall Street corporation. The primary care professionals collectively, loosely arranged within a community and interacting with the specialized services and facilities available, or a community health center, or an integrated delivery system such as Kaiser Permanente, would be examples of the type of primary care infrastructure that would serve us well.

This comment clearly is not an endorsement of privatized Medicare or Medicaid, but it is a recognition that an individual representing the medical-industrial complex can still have the wisdom to recognize what a con the consumer-directed movement in health care has been. So we should to listen to everyone but reject the bad while implementing the good.

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Patients will decide how they spend NHS money

By Chris Smyth
The Times, April 16, 2018

Hundreds of thousands of people will receive personal allowances of NHS cash to organise their own care as ministers seek to “put power back into the hands of patients”.

Far more people with mental health problems, dementia and physical and learning disabilities will have the right to select and pay for treatments they want. The money will be paid directly to them and can be spent on whatever that they think best helps to manage their condition, as long as a doctor agrees.

Veterans leaving the army and wheelchair users have also been promised the “personal health budgets” after complaints that care provided to these groups by the NHS is not good enough. Some such budgets run to tens of thousands of pounds.

The reforms will allow recipients to employ relatives or neighbours as carers, buy specific pieces of equipment, enrol in exercise classes or hire a personal assistant. The policy has been controversial in the past because such budgets have been spent on holidays, horse-riding lessons and aromatherapy.

At present 23,000 people have personal budgets in the NHS through a little-known initiative called NHS Continuing Healthcare, designed for those who need both social care and nursing. Now ministers want an “exponential” expansion of the right to have personal health budgets, taking the number up to 350,000.

Giving patients the personal responsibility for their healthcare on such a scale is compared by some to Margaret Thatcher’s decision to allow tenants to buy their council homes. The reform is also significant for combining money from the health and social care budgets, a wider goal for health reformers.

Caroline Dinenage, the care minister, said: “If you have complex needs our current health and social care system can be confusing, so it’s right people should be involved in the important decisions about how their care is delivered. These changes will put the power back into the hands of patients and their families.”

Some on the left fear that personal budgets will lead to privatisation of the NHS, as money is diverted from existing services based on consumer choice. Right-wing critics fear that the money could be spent frivolously.

The budgets have the backing of Jeremy Hunt, the health secretary, and Simon Stevens, the head of the NHS. Mr Hunt is preparing to lay out plans later this year to reform social care.

Ms Dinenage insisted that personal budgets for patients would “not only improve quality of life and the care they receive, they will offer good value for money for the taxpayer and reduce pressure on emergency care by joining up health and social care services at a local level.”

Ministers see the policy as a way to let individuals tailor their own care, circumventing cumbersome attempts to make fragmented health services work more closely together. They point to evidence that people’s health improves if they can spend NHS money on what matters to them, while cutting costs by 17 per cent on average by stopping expenditure on unhelpful treatment.

Supporters have defended purchases of computer equipment or football tickets, saying that such items can be crucial in helping people with complex conditions to thrive, with all spending signed off by doctors. Money for personal assistants and iPads can be justified if doctors think that this will help people to organise treatment or live independently, they say. The budgets cannot be spent on alcohol, tobacco, gambling, debt repayment and illegal activities.

Nigel Edwards, chief executive of the Nuffield Trust think tank, said that for people with suitable long-term conditions that were too complex for existing services there was good evidence that personal budgets worked. “It appears that giving people flexibility and choice over the care they require produces better outcomes for them [and does] produce some relatively modest savings,” he said. He added that concerns about “what happens if I take a personal budget and spend the whole lot on a world cruise” had so far turned out to be groundless. “There’s a danger of being closed-minded and saying ‘that’s not a real health need’ and not taking the wider view,” he said. “There will be examples of football season tickets, which get people upset, but I don’t think it’s systemic. Most of the money goes on direct care and is often justifiable.” Uptake of personal health budgets had been hampered by resistance from doctors, saying: “There is a slight suspicion of handing over control.”

However, Caroline Abrahams, of Age UK, said: “Older people in declining health with social care needs generally tell us they are not very interested in getting involved in organising the services they receive, they just want them to be effective and joined up, and delivered by kind and skilful professionals.”

John O’Connell, chief executive of the TaxPayers’ Alliance, said that “the NHS has been run in the interests of staff, not patients, so it’s very encouraging to see personal health budgets being expanded”, but cautioned: “The government can’t allow patients . . . to spend taxpayers’ money on ineffective treatments.”

https://www.thetimes.co.uk…

The British National Health Service has established “personal health budgets” – personal allowances of NHS cash to “put power back into the hands of patients.” Their conservative government now intends to greatly expand the use of these accounts. Some fear that this represents an effort to further privatize the NHS – moving cash into the hands of patients while reducing funds for the already underfunded NHS.

These personal budgets have in common with our health savings accounts the concept that somehow patients will be better health care shoppers if they are using cash, but the improvement in the targeting of spending is largely negligible and only at the margin. Patients do not have the ability to judge the best value in most health care purchasing, not because they are not intelligent but because they are relatively uninformed (and, no, price lists do not provide patients the information that they would need).

NHS is a prepaid health care program that does not require payments associated with care received, and thus financial barriers to access are removed. That does mean that the government needs to be sure that adequate funding of the program is maintained and that services are upgraded (or downgraded) as appropriate. Services that are truly appropriate for health care should be funded by the program and not by relatively unrestricted cash accounts that can be diverted to worthless care or to pleasures that stretch the definition of therapeutic, especially when that cash is either a disbursement of government funds or represents a tax expenditure as with our HSAs.

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Des Moines Register editorial writer wins Pulitzer Prize

Des Moines Register, April 16, 2018

Andie Dominick, an editorial writer at the Des Moines Register, on Monday won the 2018 Pulitzer Prize for editorial writing for a selection of Iowa-focused editorials criticizing policies that restrict access to health care.

The Pulitzer Prize citation states that Dominick won “for examining in a clear, indignant voice, free of cliché or sentimentality, the damaging consequences for poor Iowa residents of privatizing the state’s administration of Medicaid.”

The Register invited Iowans to share the experiences they have had with Medicaid under privatized management, which allowed Dominick to put a human face on denials of care, loss of access to services, and providers going out of business because they were not being reimbursed by for-profit insurers.

Dominick called health care “a passion of mine” and said she was honored to be recognized for her work on such an important topic.

“It’s such an honor to be recognized for the whole paper’s work on Medicaid and ensuring Iowans have access to health care,” Dominick said. “And we’ll continue to work to make Iowa a better place to live.”

(The article includes links to nine editorials such as, “Branstad’s private Medicaid ‘success’ that wasn’t” and “Privatized Medicaid is worst prank ever.”)

https://www.desmoinesregister.com…

***

The Register’s Editorial: Why tie insurance to jobs?

Des Moines Register, August 27, 2013

Employer-based health insurance creates problems for workers. They are at the mercy of their company when it comes to which plans are available.

In some ways, the health reform law addresses some of these problems.

Yet the Affordable Care Act is built on a broken system. As the Register’s editorial board wrote for years prior to the passage of the health law in 2010, this country needs a single-payer health care system with coverage facilitated by the government. Similar to Medicare, everyone could contribute through taxation and everyone would be covered. Instead of such a change, Congress cemented in place the practice of tying health insurance to jobs by requiring many companies to offer it.

http://www.pnhp.org…

The editorial staff of the Des Moines Register has long been a leader in advocating for health care justice, having supported repeatedly a single payer health care system for the United States. Although the Pulitzer Prize committee in the past has failed to recognize the significance of the single payer editorials, at least they now acknowledge the importance of health care justice by granting their Prize to editorial writer Andie Dominick “for examining in a clear, indignant voice, free of cliché or sentimentality, the damaging consequences for poor Iowa residents of privatizing the state’s administration of Medicaid.”

We can make it our job to remind the nation that the solution advocated by the Pulitzer Prize winning editorial team of the Des Moines Register is “a single-payer health care system with coverage facilitated by the government, similar to Medicare.”

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Distribution of Visits for Chronic Conditions Between Primary Care and Specialist Providers in Medicare Shared Savings Accountable Care Organizations

By Evan, S. Cole, Cassandra Leighton, and Yuting Zhang
Medical Care, May 2018

Accountable care organizations (ACOs) are groups of health care providers who agree to be collectively accountable for the overall care and costs of a prespecified group of patients. Medicare ACOs were initiated in 2012 as part of the Affordable Care Act. Since then, over 10.5 million Medicare beneficiaries have been served by 562 ACOs participating in Medicare ACO initiatives. The largest Medicare ACO program is the Medicare Shared Savings Program (MSSP): as of January 2017, there are 480 MSSP ACOs serving 9 million assigned beneficiaries nationwide. In a shared savings arrangement, providers are encouraged to manage the health care needs of a defined patient population in the most cost-effective manner.

Medicare beneficiaries are attributed to a MSSP ACO based on where they receive the majority of their primary care5; primary care is thus seen as a central component of the Medicare ACO model. Primary care has 4 main features: first contact for access to the health system, comprehensive care for most health needs, long-term focused care with an ongoing relationship, and coordinated care when needed elsewhere. It has been well-established that health systems that emphasize access to primary care have better outcomes and generally reduced costs compared with systems with poor access to primary care. A greater focus on primary care may occur within an ACO given their financial incentives. Research on Medicare’s ACO initiatives have found that ACOs with a strong primary care orientation and workforce achieved greater savings and better care in the beginning of the program, as measured by readmissions, quality of diabetes care, and provision of preventive services.

Although these preliminary findings are notable, research on the role of primary care within ACOs and how these organizations are strategically changing their practices to optimally use primary care providers (PCPs) is still emerging. ACOs may shift visits for chronic disease management to PCPs, who can manage these conditions concurrently with other comorbidities in a more accessible and less expensive manner than specialists. Hollingsworth et al analyzed data from the 2007 National Ambulatory Medical Care Survey on primary care and specialty providers and found that specialists provide routine management of 9 chronic conditions—care which could be reallocated to comprehensive primary care.

In this paper, we focus on 8 chronic conditions: asthma, chronic kidney disease (CKD), chronic obstructive pulmonary disease, diabetes, depression, hyperlipidemia, hypertension, and rheumatoid arthritis/osteoarthritis. We chose these conditions because these chronic conditions can be managed routinely and effectively by comprehensive primary care, but in practice both PCPs and specialists frequently manage the associated care. Specifically, we examine variation in the distribution of visits for 8 chronic conditions between primary and specialty care among MSSP ACOs and the factors affecting the variation. In addition, we descriptively compare this distribution of ambulatory care utilization within MSSP ACOs and a representative sample of non–ACO-attributed Medicare beneficiaries.

From the Conclusions

In this study, we sought to understand how visits for certain chronic conditions were distributed between PCPs and specialists within MSSP ACOs and the factors that were related to primary care management of chronic conditions within ACOs. Although in aggregate we did not find large differences between ACO and non–ACO-attributed beneficiaries, we did find notable variation across ACOs. Organizationally, ACOs with a higher proportion of contracted physicians who were PCPs had higher proportions of chronic condition visits that were delivered by PCPs. This relationship was consistent for 7 of the chronic conditions we included, with the one exception being depression. In addition, ACOs with more white beneficiaries, with higher prevalence of ≥3 comorbidities, in areas with larger proportions of college-educated individuals, and with greater numbers of specialists had a smaller share of chronic condition visits delivered by PCPs.

Our findings provide an indication of how MSSP ACOs have organized care for chronic conditions early in the program. As stated above, ACOs are incentivized to provide appropriate care in the least expensive setting possible; however, it does not appear that early in implementation ACOs have, at least as a group, transitioned chronic care into primary care compared with care for non-ACO Medicare beneficiaries.

The degree to which PCPs manage chronic conditions is related to both patient population, chronic condition, and organizational factors. Many ACOs may underutilize PCPs in this role, and thus could actively shift care to less expensive primary care for potential savings to payers. Barriers to that shift could include low numbers of PCPs contracted in the ACO, and existing referral patterns and patient relationships with specialists.

https://journals.lww.com…

The concept of the accountable care organization is that a group of health care providers, working together, could provide more efficient, integrated care for which they are accountable, thus improving quality while reducing health care costs. For many fairly routine chronic conditions this seems like an ideal model to expand the use of primary care since previous studies have shown that “ACOs with a strong primary care orientation and workforce achieved greater savings and better care.”

Although “ACOs are incentivized to provide appropriate care in the least expensive setting possible,” according to this study, “it does not appear that early in implementation ACOs have, at least as a group, transitioned chronic care into primary care compared with care for non-ACO Medicare beneficiaries.”

An interesting finding is that ACOs with a greater number of white, college educated beneficiaries “had a smaller share of chronic condition visits delivered by primary care physicians.” This suggests that ACOS may be aligning themselves to provide two tiered health care. That is ironic since some studies have suggested that more specialized services for the better off increase health care costs yet may produce outcomes that are no better and perhaps even worse, perhaps because specialized services are sometimes more fragmented and less integrated.

The fact that we continue to perpetuate our highly fragmented, dysfunctional health care financing system may play some role in our inability to achieve higher performance at lower costs while including everyone, as all other wealthy nations have done. The system that seems ideal for the United States is a well designed single payer national health program – an improved Medicare for all. Isn’t it time that we take a serious look at a model that would actually work?

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With New Tax Savings, Drug Companies Start by Rewarding Shareholders, Not Patients Struggling with Skyrocketing Prices

The Office of U.S. Senator Cory A. Booker, April 9, 2018

In December 2017, President Trump and the Republican-led Congress enacted the Tax Cuts and Jobs Act, a $1.5 trillion bill that delivers massive tax cuts to the nation’s largest corporations and wealthiest families. The legislation cuts the corporate tax rate permanently from 35 percent to 21 percent, repeals the corporate alternative minimum tax, moves toward a territorial tax system that largely exempts future foreign profits from taxation, and sets a 15.5 percent repatriation rate for cash held overseas.

In anticipation of tax savings, companies have responded mainly by forecasting significant benefits for their shareholders. Over the course of three months, public companies announced more than $200 billion in stock buybacks, doubling the pace of the previous year. All told, companies are expected to spend some $450 billion of their tax savings on stock buybacks. A recent Morgan Stanley survey further projects that 43 percent of companies’ savings from the new tax law will be devoted to buying back stock and issuing dividends, actions that help companies and their predominantly wealthy shareholders.

The nation’s largest drug companies in particular are poised to reap tremendous gains from the new tax law, including through lower effective tax rates and through repatriation of billions of dollars stored overseas. The critical question that this report endeavors to answer is: how will pharmaceutical companies spend this tax windfall?

Findings: So Far, Drug Companies Are Passing Tax Savings Along to Shareholders, and Are Not Using That Money To Help Working Families Afford Medications

From January to March 2018, the office of Senator Booker reviewed the quarterly shareholder calls the first since the passage of the Tax Cuts and Jobs Act of each of the 10 largest pharmaceutical companies headquartered in the United States.

Finding 1: Shareholder Payouts

On the fourth-quarter 2017 earnings calls, the companies highlighted plans to increase the return of capital to shareholders through share repurchases and corporate dividends. Pfizer and Merck each announced $10 billion in buybacks shortly before the tax law was passed, and, in the wake of the law’s final passage, AbbVie and Amgen each announced their own $10 billion buyback plans. Those four programs, at $10 billion apiece, are among the largest new buyback plans across the entire U.S. economy. Only five other companies (Cisco, Wells Fargo, Home Depot, PepsiCo, and Oracle) have revealed larger new buyback authorizations during this period. Another pharmaceutical company, Celgene, has announced a $5 billion  buyback plan that is also among the largest so far across all industries. Other pharmaceutical companies suggested that more buyback plans were forthcoming.

The recent buyback announcements by these pharmaceutical companies total $45 billion — 21 percent of the more than $200 billion in buyback announcements made over the initial three months during and after final passage of the tax law. In other words: just five pharmaceutical companies were responsible for about one-fifth of the value of all the new buyback announcements made across the economy.

Finding 2: Drug Price Changes

None of the reviewed pharmaceutical companies announced or forecast lowering prescription drug  prices as a result of anticipated tax savings. Instead, some companies discussed pricing concerns at a general level during their earning calls, expressed caution about providing specific pricing guidance, or acknowledged that patients struggle with affordability. None indicated that the massive tax windfall would  prompt them to lower prices and ease the heavy cost burden on patients. In fact, many companies have actually instituted drug price increases for 2018.

Finding 3: Other Projects

On their most recent quarterly shareholder calls, many of the top pharmaceutical companies highlighted the substantial benefits they have received, and will receive, from the new tax legislation. They detailed their plans for spending those savings with varying degrees of specificity. Stock buybacks, as noted, were a major focus of many companies. But they also announced various other projects, including capital investments, research and development, one-time benefits to workers, charitable contributions, and  business development. Still, for many of the announcements, it is unclear how much of the outlays are actually attributable to the tax cuts, and how much would have been spent independent of the tax cuts.

From the Conclusion

Recent earnings calls provided top drug companies their first significant opportunity to demonstrate how they would spend their windfall from the Tax Cuts and Jobs Act. So far, the influx of tax benefits from the new law has been associated mainly with a slew of stock buyback announcements — with $45 billion in new buyback programs by just five pharmaceutical companies. They are some of the largest buyback plans announced during this initial period across all industries, amounting to approximately one-fifth of the cumulative economy-wide total. Aside from stock buybacks, which predominantly benefit executives and company shareholders, some pharmaceutical companies did announce other initiatives that could help  patients and workers, such as expansions of research and development, employee pay and benefit support, capital projects, and charitable contributions.

On the earnings calls, while some pharmaceutical companies did acknowledge that many patients struggle to afford the high prices of essential prescription medications, no company announced plans to specifically use its tax savings to reduce drug prices.

https://www.scribd.com…

The tax reductions enacted last December went primarily to the wealthy and their corporations. Since there has been considerable concern about the increase in drug prices that have made them unaffordable for far too many patients, it was hoped that the pharmaceutical industry would pass some of their tax windfall down to patients in the form of lower drug prices.

No. They spent much of the windfall on buying back stocks and issuing dividends, benefiting their wealthy shareholders. “None indicated that the massive tax windfall would  prompt them to lower prices and ease the heavy cost burden on patients. In fact, many companies have actually instituted drug price increases for 2018.”

This should come as no surprise since Congress and the President, as an ideological goal, have been striving to reduce public funding of health care benefits. It seems that the politicians in control and their wealthy benefactors do not care about the health of the people nearly as much as they care about further increasing the wealth of those already wealthy.

It’s about policy, but we won’t get it right until we fix the politics.

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A slim majority of Americans support a national government-run health care program

The Washington Post, April 12, 2018

Washington Post-Kaiser Family Foundation Poll

Q: Do you support or oppose having a national health plan–or a single-payer plan–in which all Americans would get their insurance from a single government plan?

51% – Support
43% – Oppose
4% – Don’t know
2% – Refused

https://www.washingtonpost.com…

Previous polls on single payer Medicare for all have indicated that there is majority support for the concept but that the support is malleable and declines when referred to as a government plan. This poll question referred to “a national health plan,” “a single-payer plan,” while stating “Americans would get their insurance from a single government plan,” without any mention of Medicare for all. So the opposition to having a “government plan” seems to be subsiding, though we still have a long way to go in educating our fellow Americans on the vast superiority of the model.

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New Tax Refund Data: Earliest Filers Get Largest Refunds, Spend More on Healthcare

JPMorgan Chase & Co., April 10, 2018

Today the JPMorgan Chase Institute released the first analysis since the 1980s of American’s tax refunds by income and other demographic characteristics. The research, Who Files Early and Who Defers Healthcare: Insights from 1.2 Million Tax Refunds, also includes a first-ever analysis of the impact of tax refunds on healthcare spending for different income and other demographic groups. The research finds Americans in all income groups who were owed larger refunds filed their taxes earlier, and those who filed their taxes earlier also spent more of their annual tax refund on healthcare services they had been deferring.

The earliest filers, those who received refunds in February, responded more sharply to the tax refund with a 38 percent increase in healthcare spending over 76 days, compared to a 22 percent increase for those who received refunds in March and an 11 percent increase for those who received refunds in April or May. Among the earliest filers, 64 percent of their healthcare spending response to the refund went to deferred healthcare services (spending represented by payments that were made in-person at healthcare providers), compared with just over 55 percent for accounts held by the latest filers. Almost all of the remaining healthcare spending response in all groups went to paying deferred medical bills; only a tiny fraction went to paying for healthcare goods that could be stockpiled.

“It’s increasingly clear that families are using their tax refunds as a zero-interest savings vehicle. If consumers have a health need at some other time of the year, they might have to delay treatment until cash arrives during tax time,” said Diana Farrell, President and CEO, JPMorgan Chase Institute. “These consumers would benefit from alternative savings vehicles or a more flexible refund system so they can access savings for healthcare whenever they need it.”

In January 2018, the JPMorgan Chase Institute released new findings identifying a 60 percent increase in deferred healthcare spending during the week a tax refund arrives in checking accounts.

The report found the overall level of healthcare spending is 60 percent higher in the week after receiving a tax refund payment than in a typical week over the 100 days before. In the week after receiving a tax refund, out-of-pocket healthcare spending on debit cards increased by 83 percent, while there was no offsetting change to credit card spending—suggesting the cash infusion provided by the tax refund was a major determining factor driving changes in healthcare spending behavior. Moreover, 62 percent of the additional healthcare spending triggered by the tax refund was paid in person at healthcare providers. This means that cash flow dynamics influenced not just when consumers paid for healthcare but also when they received it.

The reports leverage data on daily healthcare spending for 1.2 million checking account holders in the JPMorgan Chase Institute Healthcare Out-of-Pocket Spending Panel (JPMCI HOSP) who received a tax refund in 2016. The HOSP data asset was first constructed in September 2017. The asset follows a sample of 2.3 million de-identified regular Chase customers aged 18 to 64 from January 2013 until December 2016. The Institute defined out-of-pocket healthcare spending as any observed payments to healthcare providers and drugstores, including co-payments, co-insurance, deductibles and other point-of-service medical, dental, or drug spending.

https://www.jpmorganchase.com…

Filing Taxes Early, Getting Healthcare Late: Insights from 1.2 Million Households
https://www.jpmorganchase.com…

Directly related to our dysfunctional health care financing system, this study shows that many people depend on their income tax refund to determine not only the timing of their payment for health care but also the timing of when they receive their health care – often deferred because of waiting for the tax refund.

Although some care can be deferred without untoward outcomes, deferral can be hazardous because conditions can deteriorate, not to mention that symptoms may be prolonged unnecessarily.

The JPMorgan Chase report suggests that alternate methods of cash management be considered rather than having to wait for tax season to receive the cash infusion needed for health care. Obviously those who do not receive a tax refund and do not have cash reserves may be out of luck and not receive the deferred care that they should have.

There is a far better way. A well designed single payer national health program without deductibles, copayments, or coinsurance removes financial barriers to health care access so there is no need to defer care. Also there is no concern about needing a tax refund to pay prior medical bills since health care has already been prepaid painlessly through equitable taxes.

Prepaid health care is one of the more important improvements in an Improved Medicare for All. What are we waiting for?

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Long-term issues confronting Medicare Accountable Care Organizations (ACOs)

By David Glass, Sydney McClendon, and Jeff Stensland
MedPAC, April 6, 2018

Slide 3:

Medicare ACOs

Groups of providers held accountable for the cost and quality of care for a group of beneficiaries

Goals of ACOs:

• Improve provider accountability
• Increase quality of care and patient experience
• Lower costs

If ACOs are successful, they are rewarded with shared savings.

Slide 16:

Are ACOs only a transition step to Medicare Advantage plans?

• Eventually ACOs will want to be MA plans because that is the most efficient model
• MA plans require beneficiary enrollment and have higher administrative costs
• We found in some markets ACOs were the low-cost model
  • Lower administrative cost
  • If ACO dominant, may get benefits of limited network without ‘lock-in’

http://www.medpac.gov…

We really do need to listen to what MedPAC (Medicare Payment Advisory Committee) has to say since it is the source of much of the legislative changes in Medicare financing, and we have to live with what the committee members produce once it is sanctioned by Congress.

SGR (sustainable growth rate) was a failure in trying to control Medicare spending and thus was replaced by MIPs (Merit-based Incentive Payment System) and APMs (Alternative Payment Models). Although the Trump administration is moving forward with MIPS, MedPAC has recognized that it is already a failure and has recommended that it be terminated and that transition into APMs be accelerated.

Although concepts of APMs are not settled it looks like ACOs (accountable care organizations) are going to be the primary model of APMs, and they are already being pushed heavily as a means of paying for value instead of volume.

Although ACOs have some vague similarities to HMOs, there are ill-defined features that remain a problem. Patients do not enroll in ACOs, so who is accountable for their care? It is difficult enough to decide who is providing their primary care when there are so many other sources of care, and it is especially difficult to assign specialists to specific ACOs. Although most ACOs are currently one-sided (upside risk only), there is an effort to push them into two-sided models (upside and downside risk), supposedly with the promise of greater savings for Medicare.

ACO managers understandably are hesitant to accept downside risk since it requires them to reduce their spending (reduce their revenues) which really means reducing health care services for patients. Cold hearted businessmen may not have problems with that if they can convert some of the savings into profits, but most health care professionals would resent being continually hounded to cut back on the amount of care they are delivering.

It appears that, instead of abandoning the ACO concept, our policymakers want to move forward with the concept because it would reduce volume by reducing patient care services, and supposedly increase value by being able to care for more patients with reduced services without increasing net costs.

But to move forward, the ACO model must be better defined. It has been suggested that an ACO must define which primary care practitioners, specialists and hospitals are in the ACO, i.e., networks must be established. Also patients must be specifically assigned to a given ACO, i.e., enrolled, even if by default. Specific financing arrangements must be made whether capitation, bundling, or even fee-for-service for those services that do not fit into a neat package. It’s astonishing how these geniuses in health policy come up with these innovative ideas. Little does it matter that their concept of ACOs is remarkably like HMOs and PPOs of the past.

So where does that put us? Well, Medicare already has something like that in place – the private Medicare Advantage plans. So it has been suggested that Medicare providers form two-sided ACOs as APMs and then transition them into Medicare Advantage plans in which eventually all Medicare patients are enrolled. Talk about a devious way of setting up premium support (vouchers for privatized Medicare).

Apparently it is such a sure thing that House Speaker Paul Ryan, for whom Medicare premium support has been his career dream, today announced his retirement. Well, maybe not quite that sure of a thing, but defensive posturing is not enough. We need to take the offensive on behalf of a well designed single payer national health program – an Improved Medicare for All.

Reform must put patients first, not the medical-industrial complex. Create the system to serve patients well, and it will work just fine for those legitimately employed in the health care delivery system.

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CMS issues final 2019 Payment Notice Rule to increase access to affordable health plans for Americans suffering from high Obamacare premiums

CMS.gov, April 9, 2018

Today, the Centers for Medicare & Medicaid Services (CMS) issued the HHS Notice of Benefit and Payment Parameters for 2019. The final rule will mitigate the harmful impacts of Obamacare and empower states to regulate their insurance market. The rule will do this by advancing the Administration’s goals to increase state flexibility, improve affordability, strengthen program integrity, empower consumers, promote stability, and reduce unnecessary regulatory burdens imposed by the Patient Protection and Affordable Care Act.

“Too many Americans are facing skyrocketing premiums that they can’t afford and every year consumers are faced with the threat of fewer choices. This rule gives states new tools to stabilize their health insurance markets and empower citizens to find coverage that fits their families’ needs and budgets,” said CMS Administrator Seema Verma.

The final rule issued today includes the following key provisions:

Increasing Flexibility

* Essential Health Benefits (EHB)
* States will also now be able to build their own set of benefits
* Qualified Health Plan (QHP) Certification Standards

Improving Affordability

* Exemptions

Strengthening Program Integrity

* Risk Adjustment
* Advanced Premium Tax Credit (APTC) Program Integrity

Empowering Consumers

* Special Enrollment Periods (SEPs)

Promoting Stability

* Medical Loss Ratio (MLR)

Reducing Unnecessary Regulatory Burden

* Small Business Health Options Program (SHOP)
* Rate Review

https://www.cms.gov…

Final Rule (523 pages):
https://s3.amazonaws.com…

The Trump administration is continuing its efforts to undermine the policies established by the Affordable Care Act. That would not be so bad if they were replacing it with a much better program such as an Improved Medicare for All. But no, just the opposite. They are doing what Congress failed to do and that is inflict as much damage as they can administratively. What is particularly offensive is their glowing rhetoric using terms that dishonestly imply that they are greatly improving the program.

The provisions that are being changed are listed above, and they are briefly described in the press release available at the link. A couple of examples can give you an idea of what they are doing.

ACA requires ten specific essential health benefits in the exchange plans, but the rule released allows much more flexibility in selecting the essential benefits. In a press call, CMS Administrator Seema Verma said that they wanted to allow insurers leeway to “create plans that more directly address the needs of citizens and not a one-size-fits-all D.C. mandate.” Of course, the problem with a menu of benefits is that nobody really knows what their medical needs will be next year. Benefits need to be comprehensive for everyone.

They say they would improve affordability by allowing an exemption when it is determined that coverage is not affordable based on projected income using a higher metal level plan when no bronze plan is available in the service area. Maybe it is sort of true that not buying insurance improves affordability of the exchange plans, but it sure plays havoc with affordability of health care when you are uninsured.

They are changing risk adjustment to reduce the burden on issuers, providing states “with the flexibility to request a reduction to the otherwise applicable risk adjustment transfers in the individual, small group or merged market by up to 50 percent beginning with the 2020 benefit year, which may be helpful in attracting and retaining insurers and more precisely accounting for relative risk differences in the state market.” They continue to take good care of the private insurers, but when insurers benefit financially, patients lose.

The medical loss ratio (MLR) represents the percentage of premium dollars that are paid out for health care. The new rule “allows states to request reasonable adjustments to the MLR standard for the individual market if the state shows a lower MLR standard could help stabilize its individual insurance market.” Again, this takes good care of the insurers by allowing them to spend even less than the current 80 percent requirement on health care, and, again, the patients lose.

Currently insurance premium rate increases over 10 percent must be submitted for review. The new rule changes the threshold to 15 percent. Allowing unchallenged premium increases of 15 percent year after year also takes good care of the insurers, but not so good for those paying the premiums, whether directly or through taxes.

The winners? Insurers and conservatives who want to reduce the role of government in the financing of our health care. The losers? Patients and taxpayers. That’s not good.

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Public Health Advocacy in the Tumultuous Times of the Trump Administration

By David N. Sundwall M.D.
AJPH, April 2018 (published online March 7, 2018)

Excerpts

The election of Donald J. Trump as president of the United States was an unexpected and extraordinary event in the history of our nation. His presidency has resulted in dramatic changes in our politics and our policies and unease in much of our population. Those of us committed to public health and ensuring that government programs devoted to the well-being of our citizens be sustained have been perplexed, confused, and frustrated, to say the least. We are not alone—this situation applies to much of the federal government’s agencies, the federal workforce, organizations representing the public’s interests, and our fellow Americans.

Notwithstanding this uncomfortable uncertainty…regardless of who is in the White House, we (in public health) have important and essential work to do, and we must continue to do it with the budget provided and at the direction of our elected officials. We need to do our work as well as we can with the resources provided and within the scope of the laws authorizing our activities. This does not mean, however, that those of us in public health positions, or for that matter any person or group with an interest in public health, should not advocate to sustain and strengthen our nation’s public health enterprise. An important exception is those federal employees constrained by Hatch Act, which prohibits them from engaging in political activities. (This federal law, which was passed in 1939, limits certain political activities of federal employees, as well as some state, District of Columbia, and local government employees who work in connection with federally funded programs. The law’s purposes are to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced on the basis of merit and not on the basis of political affiliation.)

So, accepting that these are difficult times when nothing seems to be done as it previously was, how do we go about advocating public health? The following are just a few of the principles I identified that I think are especially relevant to our current circumstance:

* The importance of being honest, informed, and evidence-based—earnest advocacy will not likely get very far without data and information to support a proposal.

* The importance of not judging a book by its cover—the confirmation process for US Surgeon General C. Everett Koop. Yet, once confirmed, he proved to be an effective leader and champion of public health for all, especially those infected with HIV as this epidemic unfolded during his tenure. Could our new Surgeon General, Jerome Adams, also become an outstanding advocate for public health in this position?

* The importance of building bridges—unlikely allies in working together for reauthorization of the Maternal and Child Health Care Block Grant. The Children’s Defense Fund, a liberal Washington, DC–based organization, came together with a group in South Carolina affiliated with the Southern Baptist Coalition, a staunchly conservative organization, to advocate together for the maternal and child health programs.

* The importance of science-driven policy—the National Organ Transplant Act of 1984: Notwithstanding evidence that some of our elected officials seem to be “anti-science” and do not want to be “confused by the facts,” I contend that a significant majority are not. It is essential that we use current scientific knowledge to bolster our case for new and better public health policies.

* The importance of regulations and rules in addressing policy issues—how to achieve administrative simplification, efficiency, and effectiveness by changing the rules, not the law: The opportunity to achieve policy objectives through modifying existing rules and regulations of public health laws is often overlooked. The Trump Administration is committed to such administrative simplification, deregulation, and therefore is likely to support such proposals for constructive changes.

* The importance of understanding and respecting “who’s in charge” and of nonpartisan advocacy, for public health—cultivating relationships with key elected officials: I think it is fair to generalize that, historically, most advocates for public health have favored a strong federal government role in funding public health initiatives, and have favored regulations holding states and grantees accountable to achieve improved health outcomes. The current Administration and the majority in Congress favor a more limited government role, less spending, and less regulation. The most pressing challenge for public health advocates now is to ensure adequate federal funding for public health programs. So, regardless of personal political views, we must invest time and effort to know those currently in charge—our elected officials and their staffs—to seek compromise in funding levels and regulations to sustain our public health enterprise. Our collective efforts to educate and inform key elected officials will be essential to counter harmful proposals in President Trump’s 2018 budget and also to prevent harmful provisions in the Congress’s budget proposal. We will also need to work together to correct potential problems in the recently passed tax reform legislation.

To successfully advocate sustaining and strengthening our nation’s public health enterprise, I recommend we rely on these six time-proven principles.

https://ajph.aphapublications.org…

***

Woolhandler and Himmelstein Respond

By Steffie Woolhandler M.D., M.P.H., and David U. Himmelstein M.D.

Who could disagree with Sundwall’s advice to be honest, open-minded, optimistic, and inclusive? But the Trump administration’s authoritarian, antihealth drift demands a stronger response.

Even before Trump, public health was lagging. Funding has been drifting down and death rates creeping up, driven by widening inequality and unrelenting oppression of those at the bottom of the income scale. Although President Obama may be faulted for inadequate responses, his successor has unleashed an all-out assault on the nonrich, non-Christian, nonmale, non-White, non-American—as well as on nature itself. Even George Orwell might flinch at the Centers for Disease Control and Prevention leadership’s ban on words like “science-based,” “evidence-based,” “vulnerable,” “transgender,” and “fetus.”

Yet, the defeat of frontal attacks on the Affordable Care Act (ACA) indicates that health is perilous terrain for Trumpism. The fight against repeal called out legions who packed town hall meetings, disability and other activists who braved arrest, and scholars, journal editors, and journalists who spread the word of mortal and financial consequences from uninsurance. Republicans could only sliver off the Obamacare mandate under cover of a tax bill.

But defensive efforts like those that fended off ACA repeal are not enough. Medicaid—as well as Medicare, SNAP (food stamps [Supplemental Nutrition Assistance Program]), and TANF (welfare [Temporary Assistance for Needy Families])—are also in Congress’s crosshairs. They’ll claim that the ballooning deficits ensured by the new tax law compel cuts.

During the 2016 presidential campaign, Trump’s racist and nativist appeals found fertile ground among beleaguered White working-class voters eager for scapegoats, while the wealthy and powerful needed no dog whistle to understand what Trump could do for them. In response, mainstream Democrats proffered little to ameliorate working-class pain, nor did they threaten to discomfit the wealthy.

The promise—and reality—of sweeping social changes offers the only effective antidote to the president’s reactionary populism. A full turn away from capitalism is not currently on the agenda. Yet experience in other nations—and in ours in the past—shows that redistributing income through taxes and social programs and attending to the environment can do much to improve health, while sustaining, and even spurring, overall prosperity.

Seven decades back, AJPH’s Editor Charles-Edward Winslow called for massive social investments to end the physical and emotional toll exacted “by malnutrition, by slum dwelling, by lack of medical care, by social insecurity” and urged “those who do not agree with me to mend their ways; and those who do agree with me to go forward with hope and courage.”

Such courage is now urgently needed. Public health professionals must put policies to the test of science and raise their voices to decry health-threatening ones. But we must go beyond that, joining others to organize for health-improving reforms and protest harmful initiatives.

As Sundwall notes, for many public employees (including us), politicking for candidates at work and using our employers’ resources, such as computers and e-mail addresses, are verboten. And running for office or soliciting campaign contributions may be off-limits. But while off-duty, we’re free to vote, contribute money, express our views, and protest.

The contrast between our nation’s spectacular wealth and sorry record on health and social indicators gives reason for hope as well as shame. We can readily afford to house, feed, educate, and heal all who are on our soil.

What’s needed is a new New Deal. For medical care, that means single-payer health care, not just defending Obamacare. We can find housing for the 3.5 million homeless in the 18.3 million vacant housing units; food from our abundant harvests can provide for the 41.2 million who suffer food insecurity; and funds can be diverted from the more than $800 billion our governments spend on prisons, policing, and defense to schools, mass transit, and social needs.

Politics, not economics, keeps us from ensuring that our water and air are clean, that carbon is kept from our skies, and that every community enjoys the full measure of prevention in homes, neighborhoods, workplaces, and medical offices. Envisioning what’s possible and fighting for what’s needed are not tangential to public health work. They are our core mission.

https://ajph.aphapublications.org…

Public health funding in the United States has always been a challenge as have the policy positions of our government leaders. Under the Trump administration the issues are even more difficult because of the anti-spending and anti-regulation ideology which forms a barricade to the public health spending and infrastructure that we need.

The fact that we spend so much on health care yet achieve on average only mediocrity is a sure sign that our government does not have the right policies in place. This applies not only to the health care system directly but to other elements that are essential in maintaining the health of the people. A prime example is that 3.5 million people are homeless when we have 18 million vacant housing units, just as The New York Times this week is reporting on 83 million eviction records. This is not just a failure of our public health system but a failure of our government at large.

The policies that would work are not difficult to understand, but the politics remain a barrier, which is even greater under the current administration. We would already have a single payer, improved Medicare for all if it weren’t for the politics.

David Sundwall I know personally to be a very dedicated, sincere advocate of public health policies. But he represents the all-too-prevalent view that we can do this within the political environment we have, by using his six principles. That approach alone is far too feeble, as our nation’s history demonstrates.

Steffie Woolhandler and David Himmelstein explain why we need much more than that. We need sweeping social change – a new New Deal. We have the resources. It is the politics, not the economics, that keeps us from our goals. We have to fight for what’s needed to make public health work. That must be our core mission.

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