Who needs to know what a hip replacement costs?

Posted by on Tuesday, Feb 12, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure

By Jaime A. Rosenthal; Xin Lu, MS; Peter Cram, MD, MBA
JAMA Internal Medicine, February 11, 2013

Objective – To examine whether we could obtain pricing data for a common elective surgical procedure, total hip arthroplasty (THA).

We found it difficult to obtain price information for THA and observed wide variation in the prices that were quoted. Many health care providers cannot provide reasonable price estimates.

Comment (excerpts):

The results of this study provide insight into the availability of pricing information for a common elective medical procedure, THA. We found that only 16% of a randomly selected group of US hospitals were able to provide a complete bundled price, though an additional 47% of hospitals could provide a complete price when hospitals and health care providers were contacted separately.

First and foremost, understanding our results requires an understanding of the rationale behind calls for greater pricing transparency. The desire for pricing transparency is based in fundamental principles of economics; the assumption that if patients know the prices of medical services, they will make rational decisions by avoiding high-cost health care providers ceteris paribus.

Our results are somewhat remarkable considering the support expressed by virtually all stakeholders for pricing transparency.

Irrespective of the reason for the variation we encountered, we would actually view our results with a modicum of optimism. The nearly $100 000 range in pricing that we encountered suggests that a savvy and determined customer may find opportunities for significant savings with comparison shopping. Alternatively, it is equally possible to argue that our results suggest that less-educated or less-savvy patients could pay exorbitantly high prices.



What Does a Hip Replacement Cost?

Comment on “Availability of Consumer Prices From US Hospitals for a Common Surgical Procedure”
By Andrew Steinmetz, BA; Ezekiel J. Emanuel, MD, PhD
JAMA Internal Medicine, February 11, 2013

As Rosenthal and colleagues write, there are many potential solutions for reining in costs and improving quality in American health care, but they require access to reliable information on price and quality for patients to make informed decisions. Free markets need price and quality transparency to function properly.

The history of the automobile industry shows that information asymmetry is treatable. Health care will need to travel down a similar path. It is time we stop forcing people to buy health care services blindfolded — and then blame them for not seeing. The transparency imperative is here, and one way or another the public will soon be empowered to choose their health care based on reliable data on price and quality.


There is a terrible epidemic of a mental derangement that has befouled the minds of not only those in the political, policy and academic communities, but also the minds of the public at large. This mass hysteria is exemplified by this statement extracted from the Rosenthal et al article: “Our results are somewhat remarkable considering the support expressed by virtually all stakeholders for pricing transparency.”

Almost everyone seems to be fixated on the concept that if we make health care pricing transparent, we will be able to place every individual in charge of getting the health care that they need while eliminating excessive prices and unnecessary care. The massive shift taking place to higher deductibles and other consumer-driven cost sharing is based on this principle.

Implementation of the Affordable Care Act is pushing us towards innovative changes in the way we pay for health care, such as this article which implicitly supports “bundling” as a means of obtaining a single price for complex services – to be used to shop around for cheaper providers.

With our current budgetary problems on the state and local levels, let’s look how this might play out if we expand the concept from health care to other social services.

Imagine creating price sensitivity for community fire services. Suppose we bundle the payment for putting out a house fire. Not only would we need competing fire services, but we would also need access, through a 911 call, for the various bundled prices. Or a car fire? You can be transferred to the 911 car fire operator who has the car fire bundled prices. Or a preventive fire safety inspection of your home – mandated by the Affordable Fire Act? Instead of 911, you can access eFireInspection providers for competitive fire inspection bundles, which provide basic inspection services, with options such as purchasing a place at the front of the queue in the event of multiple fires.

The police? Easy. Competing bundled prices on home invasion robberies. Murder? No problem – bundled packages with or without conviction and imprisonment of the murderer. Maintaining the peace? Are you kidding? With price transparency who would waste their money on that unnecessary service?

Education bundles? Park and recreation bundles? Public street and highway bundles? City sanitation bundles? How about bundles for politicians? You could buy only the politicians that you need.

Of course all of this is totally ridiculous. So why have we separated out our health care social services to be placed under the control of price shoppers? Isn’t there a better way?

Everyone recognizes the silliness of the examples above because we all understand that such social services are financed through global budgets established by the stewards of our taxes. With minor exceptions, the services are provided automatically without the necessity of establishing price sensitivity on accessing those services. Any additional funding requirements are addressed through the budget process.

Likewise, as in Canada, our hospitals should be globally budgeted. To do so would introduce administrative simplicity and lower costs due to greater efficiency. Physicians’ rates can be kept fair and reasonable through negotiation with the single public payer. Most other nations have shown that you can provide comprehensive care at much lower costs without requiring price transparency for health care shoppers.

Look again at the authors’ statement: “Our results are somewhat remarkable considering the support expressed by virtually all stakeholders for pricing transparency.” Price transparency as a solution for our outrageous health care costs? It’s time to bury this terribly unsound idea and move on with a system that works – a single payer national health program.

ACA health insurance tax

Posted by on Friday, Feb 8, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Tax hikes you may have forgotten about

By Alex Brill, research fellow, American Enterprise Institute
The Hill, February 7, 2013

One of the next ACA taxes scheduled to take effect is a health insurance tax that will hit small businesses and their employees particularly hard. The tax is officially imposed on health insurance companies, but the greatest effect will be felt by their customers because the insurance companies will pass most of the burden on through higher premiums. An analysis by the nonpartisan Joint Committee on Taxation found that the tax will raise insurance premiums on average by $350–$400 per affected family in 2016.

The higher premiums caused by the new tax will also prompt some employers to self-insure rather than purchase true insurance for their workers. The tax exempts employers who self-insure, as well as certain nonprofit insurers who provide more than 80 percent of their services to Medicare, Medicaid, CHIP, or dual-eligible plans.

Normally, when some taxpayers change their behavior and avoid a tax, the tax raises less revenue than might otherwise be expected. Oddly, the insurance tax is designed in a way that prevents any revenue decline. The ACA presets the insurance tax’s total revenue yield at $8 billion next year, rising to $14.3 billion by 2018. To make this possible, each year’s tax is calculated in the following year, with the preset total tax burden allocated among insurance companies based on each company’s share of the market.

If insurance companies raise premiums to cover the tax and some employers respond by self-insuring, the result will be a bigger tax on the employers that remain in the insurance market. Of course, the bigger tax would fuel another round of premium hikes, causing more employers to self-insure, further premium increases, and so on.

According to the Kaiser Family Foundation’s 2012 Survey of Employer Health Benefits, 15 percent of the smallest employers self-insure, roughly half of employers with 200–999 workers self-insure, and 93 percent of firms with more than 5,000 workers do so. Because the smallest employers almost never self-insure, they will end up bearing the brunt of the tax. Midsized firms will be most likely to shift to self-insuring their workers.

Congress and the public may not view insurance companies as sympathetic figures. But it’s the insurance companies’ customers who will be most penalized by this new tax, whether through $400 premium increases or by being forced to run the risks of self-insuring.


When we are talking about financing our health care system – 17 percent of our GDP – we have to get tax policy right. One tax being imposed by the Affordable Care Act – a tax on health insurers – will surely be passed on to purchasers of health plans in the form of higher premiums. When health health insurance premiums are already unbearable for many, it doesn’t seem wise to adopt a tax policy that pushes premiums even higher.

Another peculiarity about this tax is that self-insured employers are exempt. We have already written about the serious problems with the current trend of small businesses self-insuring – less regulatory oversight, exemption from some of the provisions of the Affordable Care Act, and the vagaries of stop-loss insurance for the self-insured. Yet the insurance tax will increase this unfortunate trend.

Since the global amount of the tax is set in law and it is assessed proportionately amongst the insurers, as many employers convert to self-insurance, the tax payment required of those continuing to be insured through private plans will rise disproportionately. Although this might not reach the level of a death spiral, the distribution would certainly be inequitable.

One of the most important features of a single payer national health program is that it would be funded through equitable tax policies. Everyone pays their fair share, based on ability. Not only could we fix our health care system through single payer reform, but we would have the additional advantage of moving us much closer to an equitable system of taxation.

What will replace SGR?

Posted by on Thursday, Feb 7, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

SGR Repeal Bill Favors Primary Care

By Robert Lowes
Medscape Medical News, February 6, 2013

Two members of Congress today reintroduced an ambitious bill that would repeal Medicare’s sustainable growth rate (SGR) formula for setting physician pay and gradually phase out fee-for-service (FFS) reimbursement.

One major difference this time around for the bipartisan bill, originally introduced in May 2012, is that its price tag appears considerably lower, making passage more likely.

When Reps. Allyson Schwartz (D-PA) and Joe Heck, MD (R-NV), proposed this legislation last year, the Congressional Budget Office (CBO) had estimated that repealing the SGR and merely freezing current Medicare rates for 10 years would cost roughly $320 billion.

Since then, the CBO has reduced that 10-year estimate on the basis of lower than projected Medicare spending on physician services for the past 3 years. In a budget forecast released yesterday, the agency put the cost of a 10-year rate freeze at $138 billion.

The immediate effect of the bill from Schwartz and Heck, titled the Medicare Physician Payment Innovation Act, would be to avert a Medicare pay cut of roughly 25% on January 1, 2014, that is mandated by the SGR formula. Instead, the bill maintains 2013 rates through the end of 2014.

After 2014, Medicare would begin to shift from FFS to a methodology that rewards physicians for the quality and efficiency of patient care. From 2015 through 2018, the rates for primary care, preventive, and care coordination services would increase annually by 2.5% for physicians for whom 60% of Medicare allowables fall into these categories. Medicare rates for all other physician services would rise annually by 0.5%.

Meanwhile, the bill calls on the Centers for Medicare & Medicaid Services (CMS) to step up its efforts to test and evaluate new models of delivering and paying for healthcare (experiments with medical homes, accountable care organizations, and bundled payments are already underway). By October 2017, CMS must give physicians its best menu of new models to choose from. Two menu options would allow some physicians unable to fully revolutionize to participate in a modified FFS scheme.

The year to transition from FFS to “high quality, high value care” will be 2019 under the legislation. Physicians will either operate in a new, CMS-approved delivery and payment model of their choosing or traditional FFS Medicare. The government would keep FFS rates in 2019 at 2018 levels.

After 2019, physicians still embracing traditional FFS Medicare would see their rates reduced until 2024, when they would be permanently frozen at 2023 levels. Physicians operating in the new models, in contrast, would have the opportunity to earn raises for high-quality, low-cost care.


A summary of the MEDICARE PHYSICIAN PAYMENT INNOVATION ACT OF 2013 can be downloaded by clicking on the link at the bottom of Rep. Allyson Schwartz’s press release:

The Medicare sustainable growth rate (SGR) formula seemed to be an equitable method of slowing the non-sustainable increases in Medicare spending. What happened?

Health care spending continued to increase at very high rates, and these increases were funded by private commercial insurance plans. The funds paid pumped up the supply side in health care while having very little ameliorating impact on the demand side. As our health care system continued to be richly funded (too richly, when compared to other wealthy nations), the Medicare SGR formula fell further behind each year in meeting this ever-increasing demand for more funds.

It soon became apparent that if the SGR rates were imposed, physicians would likely restrict their participation in the Medicare program, first by not accepting new patients, and eventually many of them would drop out of the program altogether. For that reason the SGR reductions were deferred most years, and now they have grown to a deficit of about 26 percent.

When physicians are already dissatisfied with Medicare payment rates (cumulative increases have been less than the medical inflation rate), a further abrupt reduction of 26 percent would surely cause many physicians to bail – either limiting their practices to privately insured patients, or retiring early if the reductions wipe out net income.

Members of Congress do support Medicare, even if some would want to shift costs from the federal budget to the beneficiaries themselves. They do understand that the guillotine effect of imposing these reductions would likely severely impair access for patients due to a lack of willing providers. They know that they have to do something.

In defining this problem, members off Congress think in terms of the federal budget. By postponing the reductions, the money has already been spent, yet it is carried on the books as a deficit. What can Congress do to remove this deficit from the budget without having to increase federal revenues?

Quite simply, they need to find other ways to reduce the projected increases in spending. If you download the summary of the Medicare Physician Payment Innovation Act of 2013 (link above), you will see some of the schemes proposed. Most are already familiar, though many are unproven, and some ideas are innovative. Regardless, they are all methods of slowing the growth in Medicare spending while doing very little that would control spending in the private sector. We will still be faced with the same problem that we have now under SGR. In comparison with private insurance payments, Medicare will continue to trail, and the physicians will grow evermore restless.

Rather than taking one program – Medicare – and trying to make it comply with budget austerity, we need to have a financing system in which the entire health care delivery system complies with a single, universal global budget – a single payer national health program. Yes, there would continue to be turf issues between the factions competing for the funds and the public stewards of the funds, but at least the distribution would be equitable and adequate, which was the intent of SGR in the first place.

There are those who contend that we could never adhere to a budget, that it is impossible to fund all of the care that we need if we are limited by a budget. We need only to look at other nations to see that they, with their publicly supervised global or quasi-global budgets, have been able to provide quality care for everyone at an average of half of what we are spending. We can do it, and with a very rich budget at that.

National Health Service Corps and primary care

Posted by on Wednesday, Feb 6, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

National Health Service Corps expands the primary care workforce

U.S. Department of Health & Human Services, February 6, 2013

The National Health Service Corps awarded more than $10 million in funding for loan repayment to 87 medical students in 29 states, the District of Columbia and Puerto Rico, who will serve as primary care doctors and help strengthen the health care workforce, Department of Health and Human Services Secretary Kathleen Sebelius announced today.

Made possible by the Affordable Care Act, the National Health Service Corps’ Students to Service Loan Repayment Program provides financial support to fourth year primary care medical students in exchange for their service in the communities that need them most.

As a result of historic investments in the Affordable Care Act and the Recovery Act, the numbers of National Health Service Corps clinicians are at all-time highs. The number of providers serving in the Corps has nearly tripled since 2008. Today nearly 10,000 National Health Service Corps providers are providing primary care to approximately 10.4 million people at nearly 14,000 health care sites in urban, rural, and frontier areas.



NHSC Clinician Retention

National Health Service Corps

In addition to the recruitment of providers, the NHSC also works to retain primary care providers in underserved areas after their service commitment is completed to further leverage the Federal investment and to build more integrated and sustainable systems of care.

Short- and Long-Term Retention Rates

A 2012 retention assessment survey found that 82 percent of NHSC clinicians who completed their service commitment in the Corps continued to practice in underserved communities in the short-term, defined as up to one year after their service completion. Fifty-five percent of National Health Service Corps clinicians continue to practice in underserved areas 10 years after completing their service commitment.

Short-term retention increased by 28 percent when compared to the 2000 survey’s rate of 64 percent. The 2012 long-term retention (10 years after service completion) of NHSC clinicians in underserved areas is 55 percent, a 6 percent increase when compared to the 2000 rate of 52 percent. Long-term retention rates are higher for those who serve in rural as opposed to urban communities.

Retention: Primary Medical Care Providers

Physicians who completed their NHSC commitment more than 10 years ago had the highest retention rates as compared with physician assistants (PAs), nurse practitioners (NPs), and certified nurse midwives (CNMs). Ten years after their service commitment was completed, the retention rate for physicians was 60 percent. For nurse practitioners and certified nurse midwives, it was 59 percent; and for physician assistants it was 42 percent.



About the NHSC

National Health Service Corps

NHSC-approved sites are health care facilities that provide outpatient, ambulatory, primary health services in Health Professional Shortage Areas (HPSAs), which are communities with limited access to care. Sites (with the exception of Federally Qualified Health Centers and Indian Health Service sites) must apply to become an NHSC site.  Once approved, NHSC sites gain access to desperately-needed primary care providers. NHSC providers often continue to work at their sites after they complete their NHSC service commitments.

Strengthening and growing our primary care workforce is critical to keeping this nation healthy. As more Americans gain access to health care, it is critical there are qualified health care providers to serve them. The NHSC, through its providers and sites, plays an important role in helping to address the country’s primary care shortage.


As we assess the severe deficiencies in our primary care infrastructure, it is important to recognize the phenomenal contribution of our National Health Service Corps in helping to meet the primary care needs in rural and urban Health Professional Shortage Areas.

Today’s HHS release reporting that 87 more medical students have been granted funds for student loan repayment in exchange for service in the NHSC, is great news as far as it goes, but it seems that an average of fewer than two per state is hardly a modest advance.

At a time when the politicos in Washington are talking about spending cuts, it seems that we should be reassessing programs such as this one. We should be spending more money on this important reinforcement of primary care.

Even if we had an improved Medicare for all, this program would be invaluable in helping to correct some of the structural problems within the health care delivery system. In fact, it would be great if it evolved into a program that would provide better access to ever more of us. Backing into a national health service would not be all that bad of an idea.

Patients object to physicians’ focusing on costs

Posted by on Tuesday, Feb 5, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Focus Groups Highlight That Many Patients Object To Clinicians’ Focusing On Costs

Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D. Pearson and Marion Danis
Health Affairs, February 2013


Having patients weigh costs when making medical decisions has been proposed as a way to rein in health care spending. We convened twenty-two focus groups of people with insurance to examine their willingness to discuss health care costs with clinicians and consider costs when deciding among nearly comparable clinical options. We identified the following four barriers to patients’ taking cost into account: a preference for what they perceive as the best care, regardless of expense; inexperience with making trade-offs between health and money; a lack of interest in costs borne by insurers and society as a whole; and noncooperative behavior characteristic of a “commons dilemma,” in which people act in their own self-interest although they recognize that by doing so, they are depleting limited resources. Surmounting these barriers will require new research in patient education, comprehensive efforts to shift public attitudes about health care costs, and training to prepare clinicians to discuss costs with their patients.

From a discussion of Implications

The focus-group discussions revealed the following barriers to participants’ choosing less expensive care: the salience of unlikely but highly upsetting possibilities; a desire for zero risk, rather than for reasonable risk reduction; an assumption that price always signals quality; the misperception that health care sustainability can be achieved by eliminating wasteful spending alone, without needing to forgo some marginally beneficial care; and the belief that choosing more expensive care constitutes a kind of victory for patients over the insurance companies.


If patients and clinicians do not discuss and consider costs during the clinical encounter, the alternatives are problematic. Clinicians might make cost-conscious decisions—for example, judging when high-priced resources such as operating room times, hospital beds, imaging, and specialty referrals are warranted—without informing patients that cost considerations influenced their decisions. Evidence from other countries indicates that clinicians do occasionally limit the use of medical interventions on the basis of concerns about cost. Yet another alternative would be to make cost-conscious allocation decisions at the organizational level, with minimal clinician involvement.

Given the long-term projections about health care costs in the United States, it is inevitable that physicians will face increasing pressures to deliver cost-effective care to their patients. Doing so openly, in a way that allows patients an opportunity to hear the justification for cost-conscious decisions and to be active agents in thinking through treatment choices when feasible, is consistent with physicians’ ethical duties to be transparent with patients and to provide patient-centered care.

But this study’s findings suggest that for cost to be an explicitly recognized and discussed factor in clinical decisions, public attitudes about health care costs must first undergo a significant shift.


Much attention is being directed today toward the very high costs that plague the U.S. health care system. That attention has not equated with effectiveness in controlling costs, as we witness continued increases in spending in spite of introduction of policies that may be well-meaning but not very effective, that may add to the administrative excesses of our system, and that sometimes are detrimental such as when we erect financial barriers to beneficial health care services.

Some of the emphasis has been directed toward increasing the engagement of the “medical consumer” in the decision process, often through the policies of consumer-directed health care. These policies are designed to make patients “better health care shoppers” by forcing them to recognize costs as they spend some of their own money on health care. The most common measure is to increase the deductibles and other forms of cost sharing that the patient must face when accessing care.

This important study used focus groups to determine the attitudes of potential patients toward injecting cost considerations into the delivery of health care. Patients don’t like it. They feel that they should receive the care that they should have without insurers or public programs making decisions on covering care based on cost considerations. Even if it is their own money, they do not want to compromise their care based on cost.

Other high-quality systems that are much less expensive than ours are able to provide care with first dollar coverage, eliminating the requirement that the patient be involved or even concerned about the costs of the care that they receive. We do not need to create an environment of distrust by the patient that would be engendered by thoughts of health care services being withheld for reasons of cost.

We can make far better clinical decisions based on studies generating guidelines such as those by the British National Institute for Health and Clinical Guidance (NICE). An example of how this works is in their guidance for “Cetuximab, bevacizumab and panitumumab for the treatment of metastatic colorectal cancer after first-line chemotherapy,” available at this link: http://guidance.nice.org.uk/TA242/Guidance/pdf/

If we replaced our fragmented, dysfunctional financing system with an efficient single payer system, and then applied rational decision making processes for diagnostic and therapeutic interventions, we would not have to have the patient involved in spending decisions. Those decisions could be made on a macro-system basis by better planning of system capacity and distribution, and then incorporating a greater element of evidence-based decision making.

We really don’t need angry, me-first patients provoked by having cost decisions forced upon them, particularly when the cost transparency demanded by the advocates of consumer-directed health care creates hostility towards health care professionals and third party payers whom they believe are withholding care that they should have, whether it is true or not.

CMS shows that the healthy go in and the sick come out of Medicare Advantage plans

Posted by on Monday, Feb 4, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Impact of Continued Biased Disenrollment from the Medicare Advantage Program to Fee-for-Service

By Gerald F. Riley
Centers for Medicare & Medicaid Services, Medicare & Medicaid Research Review , 2012: Volume 2, Number 4

Background: Medicare managed care enrollees who disenroll to fee-for-service (FFS) historically have worse health and higher costs than continuing enrollees and beneficiaries remaining in FFS.

Objective: To examine disenrollment patterns by analyzing Medicare payments following disenrollment from Medicare Advantage (MA) to FFS in 2007. Recent growth in the MA program, introduction of limits on timing of enrollment/disenrollment, and initiation of prescription drug benefits may have substantially changed the dynamics of disenrollment.

Conclusions: Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries, raising concerns about care experiences among sicker enrollees and increased costs to Medicare.


Despite substantial changes in policies and market characteristics of the Medicare managed care program, disenrollment to FFS continues to occur disproportionately among high-cost beneficiaries. Disenrollees had higher risk scores and incurred higher risk-adjusted payments than beneficiaries in FFS. Their high risk scores are in contrast to the risk scores of the general MA population, most of which is enrolled in plans with average risk scores similar to or less than local FFS experience (United States Government Accountability Office, 2010). Recent studies have also shown that MA plans continue to experience favorable selection through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley, 2012). These research findings suggest a pattern of selective disenrollment whereby disenrollees are sicker and more expensive than the beneficiaries who remain enrolled in MA plans. This selective disenrollment potentially increases Medicare costs through the return of high-cost beneficiaries to the FFS sector, leaving behind a healthier and lower-cost population in the capitated MA sector.

The Affordable Care Act mandated changes to MA payment methods that will result in significant decreases in payment rates and bring them closer in line with plan costs. This may intensify pressure on plans to encourage selective disenrollment.

Disenrollees from PPOs and PFFS plans incurred lower payments post-disenrollment than disenrollees from HMOs and similar types of plans, and their average payments were closer to predicted levels. Possible explanations include a less chronically ill disenrollee population from PPO and PFFS plans, or less unmet demand for services when they transitioned to FFS. Less selective disenrollment from PPO and PFFS plans may be attributable to the more extensive network of providers available under these types of plans. Beneficiaries with chronic illnesses have a greater choice of physicians to manage their conditions and have more opportunities to switch providers if they become dissatisfied with their care. This expanded choice of providers may reduce the incentives for chronically ill enrollees to leave these types of plans.


Earlier studies of the Medicare + Choice plans and more recent studies of the successor Medicare Advantage plans have shown that, when it comes to managed care, the healthy go in and the sick come out. Taxpayers are paying more for the healthier, less-costly patients who are enrolled in the Medicare Advantage plans, and then pay more for the sicker patients who return to the traditional Medicare program (adverse selection). This CMS study adds to that evidence.

One interesting finding in this study is that those enrolled in PPO or FFS Medicare Advantage plans did not show as great post-enrollment cost increases. It is likely that the patients did not experience as much of a limitation in services in PPO plans, such as those offered by Blue Cross and Blue Shield, since their networks tend to include a much larger percentage of the physician population.

There are two important take-home points here. One is that we should stop wasting taxpayer funds on both the excesses of the Medicare Advantage plans, and the costly adverse selection burden that they place on the traditional Medicare program.

The other point is that we should reject the policies of the private insurance sector that is taking away our health care choices by establishing networks of health care providers. Our traditional Medicare program includes a choice of any provider, except for the rare physician who totally opts out of the Medicare program.

For greater economy and expanded choice, we should change to a program of an improved Medicare for everyone.

Preexisting conditions, reinsurance, and risk adjustment

Posted by on Thursday, Jan 31, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

States rethink high-risk-pool plans

By Brett Norman
POLITICO, January 29, 2013

When the health exchanges open next year, they will cover some of the sickest and costliest patients, people who cannot easily get insurance precisely because they are so likely to run up bills that no insurer would want to be on the hook for.

The federal health law contains several measures designed to spread the risk and tamp down some of the expected turbulence in the market. But a recent change in how the Department of Health and Human Services plans to run a three-year, $20 billion fund — known as reinsurance — to cushion health plans that end up with lots of high-cost customers is forcing states to rethink their own timetable for shifting some of their highest-risk people into the exchanges.

The fear, of course, is that if all the sick people flood the exchanges and younger, healthier ones hold back, premiums could surge. The health law has a bunch of mechanisms to try to avert rate shock — but questions remain about how well they will work.

More than 300,000 people are now covered through special plans for people with pre-existing conditions — about 100,000 in pools created by the health law and more than 200,000 in older, state-run pools.

The federal plan was designed from the start to be temporary and to shut down as soon as the exchanges open.

But many states had planned on moving their high-risk pool populations into the exchanges slowly to mitigate the shock to the individual market. But now, the state high-risk pools may offload as many people as they can onto the exchanges as soon as they open in 2014 or risk losing a piece of that $20 billion pie.

The Affordable Care Act program requires all insurers to pay into the reinsurance fund — and to be paid out of it if they have a big share of really expensive customers in the individual market. State officials had anticipated having a voice in distributing those payments to hard-hit plans in their states, but HHS in December proposed that it would give the money to plans with enrollees that cost more than $60,000 per year. And state high-risk pools wouldn’t be eligible for the cash.

The reinsurance program is front-loaded, with $10 billion in the first year, $6 billion in the second and $4 billion in the third and final year. By year three, the hope is that a broad range of people will be in the state exchanges, balancing out the really high-cost patients.

“I don’t think it’s going to be enough — it will offset some but not all of the effect of the high-risk pools on the individual market,” said Jonathan Gruber, an MIT economist who has studied the issue in several states.



HHS Risk Adjustment Model Algorithm Instructions

Centers for Medicare and Medicaid Services
The Center for Consumer Information & Insurance Oversight

Section 1343 of the Affordable Care Act provides for a permanent risk adjustment program. To protect against potential effects of adverse selection, the risk adjustment program transfers funds from plans with relatively lower-risk enrollees to plans with relatively higher-risk enrollees. It generally applies to non-grandfathered individual and small group plans inside and outside Exchanges.

The methodology that HHS proposes to use when operating a risk adjustment program on behalf of a State would calculate a plan average risk score for each covered plan based upon the relative risk of the plan’s enrollees, and apply a payment transfer formula in order to determine risk adjustment payments and charges between plans within a risk pool within a market within a State. The proposed risk adjustment methodology addresses three considerations: (1) the newly insured population; (2) plan metal level differences and permissible rating variation; and (3) the need for risk adjustment transfers that net to zero.

The proposed risk adjustment methodology developed by HHS:

• Is developed on commercial claims data for a population similar to the expected population to be risk adjusted;
• Employs the hierarchical condition category (“HCC”) grouping logic used in the Medicare risk adjustment program, with HCCs refined and selected to reflect the expected risk adjustment population;
• Establishes concurrent risk adjustment models, one for each combination of metal level (platinum, gold, silver, bronze, catastrophic) and age group (adult, child, infant);
• Results in payment transfers that net to zero within a risk pool within a market within a State;
• Adjusts payment transfers for plan metal level, geographic rating area, induced demand, and age rating, so that transfers reflect health risk and not other cost differences; and
• Transfers funds between plans within a risk pool within a market within a State.

This document provides the detailed information needed to calculate risk scores given individual diagnoses. (The report then goes into 14 pages describing the algorithm for the HHS-Hierarchical Condition Categories risk adjustment model.)


In a single payer financing system, health care is simply paid for out of a publicly-financed, single risk pool that covers everyone, regardless of how much appropriate health care is provided to each individual.

In our current fragmented financing system, risk pools are segregated and thus are each vulnerable to an influx of high-cost patients (adverse selection). The spending on an excess of high-cost patients drives premiums up ever higher until they are no longer affordable, patients drop out, and the insurer must then shut down (death spiral).

To protect against excessive costs being borne by any single risk pool, policies have been established to cover patients who have preexisting disorders, to provide reinsurance for costs exceeding defined limits, and to transfer funds from risk pools that enrolled healthier patients to risk pools that cover more high-cost patients.

When the Affordable Care Act (ACA) was written, it was recognized that many people with preexisting conditions could not purchase insurance because the insurers wanted to keep their premiums competitive, so they refused to accept these patients. For that reason, a temporary three-year program was established to provide subsidies to new risk pools that concentrated patients with preexisting disorders. Only about 100,000 people were enrolled since the premiums were still unaffordable for many who would otherwise qualify, plus there were restrictions such as a requirement to be uninsured for at least 6 months.

Although these pools for those with preexisting disorders didn’t work very well, at least these individuals would be able to participate in the state insurance exchanges once they become operative next January 1, since ACA requires that every qualified person be accepted regardless of prior conditions (guaranteed issue).

A problem is that adding high-cost patients will drive premiums up, perhaps to a level that could precipitate a death spiral. It was thought that this would be a problem only initially, since later on the pools would be filled with younger, healthier patients who could absorb the higher costs of the sicker patients (a very dubious assumption which we will not address here).

Since this was thought to be a temporary problem, the authors of ACA added another special three-year program – a reinsurance scheme. For any enrollee whose costs exceed $60,000 per year, the government would pick up the balance. Many believe that the $20 billion to be authorized over the three years of the program is not enough to cover the anticipated need.

Well, by the time that plan is terminated, there will have been established a permanent plan to address this problem of unequal distribution of risk between these segregated risk pools – a risk adjustment scheme. This is to be done through the HHS-Hierarchical Condition Categories risk adjustment model mentioned above.

It should be pointed out that a fairly recent study of the Hierarchical Condition model used for Medicare Advantage plans has demonstrated that the private insurers have already learned how to game the system, making patients appear much more ill than they really are (NBER Working Paper No. 16977, April 2011).

It’s too bad since, by enacting a single payer system, Congress could have eliminated the need for temporary high-risk pools, the need for temporary reinsurance, and, especially, the need for risk adjustment schemes which the private insurers will always manipulate to their own advantage.

You might want to click on the link to the HHS Risk Adjustment Model Algorithm (above) and skim through the pages just to get a feeling of the complexity of the risk adjustment process. Better yet, click on the following link and in one picture you’ll understand how the process really works:


“Shared responsibility payment” buys you nothing

Posted by on Wednesday, Jan 30, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Fact Sheet: Individual Shared Responsibility for Health Insurance Coverage and Minimum Essential Coverage Proposed Rules

Centers for Medicare and Medicaid Services
January 30, 2013

Under the Affordable Care Act, the Federal government, State governments, insurers, employers, and individuals are given shared responsibility to reform and improve the availability, quality, and affordability of health insurance coverage in the United States. Starting in 2014, the individual shared responsibility provision calls for each individual to have basic health insurance coverage (known as minimum essential coverage), qualify for an exemption, or make a shared responsibility payment when filing a federal income tax return.

Highlights of the Proposed Regulations

A principle in implementing the individual shared responsibility provision is that the shared responsibility payment should not apply to any taxpayer for whom coverage is unaffordable, who has other good cause for going without coverage, or who goes without coverage for only a short time.  The proposed regulations include several rules to implement this principle.

For example:

Hardship Exemption Clarified to Protect Taxpayers, Address Key Concerns

The statute gives HHS authority to exempt individuals determined to “have suffered a hardship with respect to the capability to obtain coverage.”  In developing these proposed regulations, HHS considered several particular circumstances that provide good cause to go without coverage.  To provide clarity for taxpayers facing these circumstances, the HHS proposed regulations enumerate several situations that will always be treated as constituting a hardship and therefore allow for an exemption.  Hardship exemptions include:

* Individuals whom an Exchange projects will have no offer of affordable coverage (even if, due to a change in circumstance during the year, it turns out that the coverage would have been affordable).  This rule will protect individuals who turn down coverage because the Exchange projects it will be unaffordable but whose actual income for the year turns out to be higher so they are not eligible for the affordability exemption;

* Certain individuals who are not required to file an income tax return but who technically fall outside the statutory exemption for those with household income below the filing threshold; and

* Individuals who would be eligible for Medicaid but for a state’s choice not to expand Medicaid eligibility.  This rule will protect individuals in states that, pursuant to the Supreme Court decision, choose not to expand Medicaid eligibility.

The HHS regulations also provide that the hardship exemption will be available on a case-by-case basis for individuals who face other unexpected personal or financial circumstances that prevent them from obtaining coverage.

Specific Rules and Process for Receiving an Exemption

The proposed regulations also codify the statute’s nine categories of individuals who are exempt from the shared responsibility payment. These categories are as follows:

Individuals who cannot afford coverage;
Taxpayers with income below the filing threshold;
Members of Indian tribes;
Individuals who experience short coverage gaps.
Religious conscience;
Members of a health care sharing ministry;
Incarcerated individuals; and
Individuals who are not lawfully present.

http://www.cms.gov/apps/media/fact_sheets.asp (Select the Fact Sheet on “Individual Shared Responsibility…” dated January 30, 2013.)

Today CMS and the IRS released two sets of proposed rules which included the exemptions that will be allowed to avoid having to pay a penalty for not being insured.

Basically, the exempt individuals will be those for whom there are no affordable plans, those whose income falls below the threshold for filing tax returns, or those who would qualify for Medicaid under federal law but their state elected not to expand eligibility. A few other exemptions are listed in the excerpts above.

One concern in the actual rule (though not listed in the CMS Fact Sheet) is that the exemption for individuals who would otherwise have to pay more than 9.5% of their income for their share of the premium of an employer-sponsored plan applies only to the employee’s coverage, but not to coverage of the family members as well. At today’s premiums, this means that an employee could pay much more than 9.5% of income if the family were to be included under the employer-sponsored plan, and that would be just for the premiums. The deductibles and other cost sharing would be in addition.

It is interesting that, instead of calling the penalty for being uninsured a tax or a fine, CMS now calls it a “shared responsibility payment,” a payment to be made when filing a federal income tax return. It is ironic that this shared responsibility payment buys you… nothing!

With all of the administrative waste that characterizes our health care system, this rule adds even more administration complexity by providing opportunities to allow individuals to remain uninsured. And the reward is, if they qualify, they don’t have to make a shared responsibility payment. Hurray!

What happened to the reform advocates who were trying to advance policies that would ensure that everyone was covered? Didn’t they have a say in this process? Oh, that’s right. Sen. Baucus had them arrested.

Senate HELP hearing on primary care

Posted by on Tuesday, Jan 29, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

30 Million New Patients and 11 Months to Go: Who Will Provide Their Primary Care?

Subcommittee Hearing, Committee on Health, Education, Labor and Pensions
United States Senate, January 29, 2013

Primary Care Access
A Report from Chairman Bernard Sanders


The primary health care system in America and its workforce is in significant need of a checkup. As the population grows and ages, as more doctors retire, and as the primary care pipeline dries up, we face a severe shortage of providers. The result is that millions of Americans are not getting the care that they need now and the situation may only get worse. Although the ACA took important steps towards expanding access points by increasing funding for community health centers and the National Health Service Corps, for example, the tremendous scope of the problem requires further attention and action. Just like an illness from which it will be more difficult and costly to recover from the longer we wait, we must take steps now to address the primary care access crisis in America.


Video of the hearing (2 hours):

Written testimonies of the witnesses:

Fitzhugh Mullan, MD , Murdock Head Professor of Medicine and Health Policy at the George Washington University School of Public Health and Professor of Pediatrics at the George Washington University School of Medicine, Washington, DC:

Tess Stack Kuenning, CNS, MS, RN , Executive Director, Bi-State Primary Care Association, Montpelier, VT:

Toni Decklever, MA, RN , Government Affairs, Wyoming Nurses Association, Cheyenne, WY:

Andrew Wilper, MD, MPH , Acting Chief of Medicine, VA Medical Center, Boise, ID:

Uwe Reinhardt, PhD , James Madison Professor of Political Economy and Professor of Economics and Public Affairs, Princeton University, Princeton, NJ:

Claudia Fegan, MD , Chief Medical Officer, John H. Stroger Jr. Hospital of Cook County, Chicago, IL:

We have a crisis in primary care. Unless we improve and expand our primary care infrastructure, we will become more dependent on the alternatives: overuse of emergency departments, fragmented care in walk-in clinics, traveling large distances from rural communities devoid of primary care, excessive use of direct access to specialized services limited to those who can afford it, and, worst of all, limited or no health care access for those who are uninsured and cannot afford it.

Today’s hearing of the Senate HELP Committee is important because it brings attention to the seriousness of this problem, demonstrating that action is an imperative. Although, as you read this, you do not have time to watch a 2 hour video nor read a half dozen testimonies, links are provided so that you can access these resources later – perhaps during the weekend when many of you have more time. If not, these links can be saved for later reference.

Although this session was focused on primary care, a couple of comments from the testimony of Claudia Fegan are apropos because of the larger needs in health care. Claudia is not only Chief Medical Officer of Cook County Hospital, she is also a former President of Physicians for a National Health Program. She understands that primary care would function much better if we had comprehensive health care reform.

As she states, “If we would enact a single-payer national health program, where everyone was entitled to health care as a right, we could focus on delivering to our patients the best care in the world and relieve our physicians of the administrative hassles…”

And her plea to the members of the Senate HELP Committee, “I urge you to work to make a difference, not for me or you, but for the patients I have the privilege of serving, who desperately need their elected officials to care about what happens to them.”

And isn’t her advocacy truly representative of the essence of primary care?

Bill Keller on P4P and single payer

Posted by on Monday, Jan 28, 2013

This entry is from Dr. McCanne's Quote of the Day, a daily health policy update on the single-payer health care reform movement. The QotD is archived on PNHP's website.

Carrots for Doctors

By Bill Keller
The New York Times, January 27, 2013

With its ambitious proposal to pay doctors in public hospitals based on the quality of their work — not the number of tests they order, pills they prescribe or procedures they perform — New York City has hopped aboard the biggest bandwagon in health care. Pay for performance, or P4P in the jargon, is embraced by right and left. It has long been the favorite egghead prescription for our absurdly overpriced, underperforming health care system. The logic seems unassailable: Reward quality, and you will get quality. Stop rewarding waste, and you will get less waste. QED! P4P!

If only it worked.

For if you spend a little time with the P4P skeptics — a data-bearing minority among physicians and health economists — you will come away full of doubts. In practice, pay for performance does little to improve outcomes or to control costs.

The first problem with P4P is that it does not address the biggest problem. Americans spend more than twice as much per capita as other developed countries on health care — a crippling 18 percent of the country’s economic output, and growing.

But the main reason everything costs less in other countries is that other countries tend to have one big payer — usually the government — with the clout to bargain down prices. A single-payer system has, so far, proven politically unpalatable in this country.


Bill Keller, the former executive editor of The New York Times, explains why pay-for-performance (P4P) is a false solution to the problems of high health care costs and mediocre quality. Although he recognizes the correct solution – a single payer system – he follows the lead of other journalists and politicians in immediately dismissing it as being “politically unpalatable.”

Was Medicare politically unpalatable?

Consider the following oft-expressed concept. “Single payer is the solution that would bring health care to everyone at a cost that we can afford; therefore we shouldn’t adopt it because of concerns about political feasibility.” Phrased this way, obviously this is a non sequitur.

Let’s jam single payer into its proper place in government. The we’ll see how politically unpalatable it is, or rather is not.

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