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.
What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?
By Marsha Gold and Giselle Casillas
Kaiser Family Foundation, November 6, 2014
This literature review synthesizes the findings of studies that focus specifically on Medicare and have been published between the year 2000 and early 2014. Forty-five studies met the criteria for selection, including 40 that made direct comparisons between Medicare health plans and traditional Medicare. An additional five studies are included, even though they have no traditional Medicare comparison group.
Despite great interest in comparisons between traditional Medicare and Medicare Advantage, studies comparing overall quality and access to care between Medicare Advantage plans and traditional Medicare tend to be based on relatively old data, and a limited set of measures.
On the one hand, the evidence indicates that Medicare HMOs tend to perform better than traditional Medicare in providing preventive services and using resources more conservatively, at least through 2009. These are metrics where HMOs have historically been strong. On the other hand, beneficiaries continue to rate traditional Medicare more favorably than Medicare Advantage plans in terms of quality and access, such as overall care and plan rating, though one study suggests that the difference may be narrowing between traditional Medicare and Medicare Advantage for the average beneficiary. Among beneficiaries who are sick, the differential between traditional Medicare and Medicare Advantage is particularly large (relative to those who are healthy), favoring traditional Medicare. Very few studies include evidence based on all types of Medicare Advantage plans, including analysis of performance for newer models, such as local and regional PPOs whose enrollment is growing.
As the beneficiary population ages, better evidence is needed on how Medicare Advantage plans perform relative to traditional Medicare for patients with significant medical needs that make them particularly vulnerable to poorer care. The ability to assess quality and access for such subgroups is limited because many data sources do not allow subgroups to be identified or have too small a sample size to support estimates. Also, in many cases, metrics employed may not be specific to the particular needs or the way a patient’s overall health and functional status or other comorbid conditions influence the care they receive.
At a time when enrollment in Medicare Advantage is growing, it is disappointing that better information is not available to inform policymaking. Our findings highlight the gaps in available evidence and reinforce the potential value of strengthening available data and other support for tracking and monitoring performance across Medicare Advantage plans and traditional Medicare as each sector evolves.
An Emerging Consensus: Medicare Advantage Is Working And Can Deliver Meaningful Reform
By Thomas Miller and James Capretta
Health Affairs Blog, November 6, 2014
The success of Medicare Advantage in recent years is changing the conversation on Medicare reform. It is now possible to envision genuine bipartisan support for fair competition between MA plans and FFS. The “premium support” concept still engenders highly politicized opposition in some quarters. But support for the idea has also begun to cross ideological divides.
Premium support is of course a complex reform. It requires risk adjustment of payments and regulation of plans to ensure fair competition. But the risk adjustment system and the regulation need not be perfect for the reform to work; indeed, the system already in place today for MA plans should provide sufficient confidence that a competitive reform model would be beneficial for the program’s participants.
The main obstacle to more intensive competition in Medicare has been distrust. MA advocates believe the bureaucracy will tilt the playing field toward FFS; and FFS defenders believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.
Today two new papers were released designed to give us greater insight on the relative value of the traditional Medicare program and the private Medicare Advantage plans. What can we learn from these reports?
It is well established that Medicare Advantage plans are paid more per patient than the costs of providing care for comparable patients in the traditional Medicare program. They continue to market their plans to healthier patients and yet they artificially magnify a touch of illness for purposes of receiving greater payments based on risk adjustment. Although the Affordable Care Act requires a gradual reduction in these overpayments, concessions have been made by the Obama administration to reduce the impact of these adjustments. The taxpayers continue to receive inferior value from their investment in the private Medicare Advantage plans.
The comprehensive literature review from Kaiser Family Foundation concludes that the information available unfortunately is quite limited. They do conclude that Medicare HMOs are able to achieve higher scores in providing preventive services – likely because of their IT systems that flag items that would improve their quality rating scores. Medicare HMOs also use resources more conservatively, which raises the concern that they could be withholding appropriate care.
Perhaps the most important conclusion from the Kaiser review is the finding that the differential in quality and access for beneficiaries who are sick is particularly large, relative to those who are healthy, between traditional Medicare and Medicare Advantage. Medicare Advantage plans may have learned how to score well on teach-to-the-test quality measures, but they fall far short of traditional Medicare in patients’ real world health care experiences.
The Health Affairs Blog article by Miller and Capretta needs to be recognized for what it is – a political tract. They claim that “evidence mounts that MA plans can deliver more efficient and higher quality care than FFS” – a claim based more on their ideological preferences for a privatized Medicare rather than on a comprehensive review of the health policy literature. They then use that conclusion to advocate for a premium support proposal that would further privatize Medicare.
They state that the main obstacle to increasing public and private Medicare plan competition is distrust. They say that Medicare Advantage advocates believe that bureaucrats will tilt the playing field toward traditional Medicare, yet the facts are that the Obama administration has been tilting the field towards the Medicare Advantage plans instead. They also say that the traditional Medicare advocates “believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.” Of course, those are not just beliefs but are well documented facts. We are paying more for private insurers to game the system at our expense.
Although neither of these reports provides new evidence that would change our opinions on private Medicare Advantage plans, they do reinforce our view that we should not listen to ideologues who care more about markets than about patients. Instead we should continue to support our traditional Medicare program that puts patients first, although we do need to improve it and then expand it to cover everyone.
by John Geyman, M.D.
Having just finished reading Bob Herbert’s excellent book, Losing Our Way: An Intimate Portrait of a Troubled America, I am struck by the parallels between trends in public education and in health care. Herbert, opinion columnist for the New York Times for 18 years and now a Distinguished Senior Fellow at Demos, a public policy think tank in New York City, describes trends in recent years in public schools in this country.
Here are some of his findings of these pervasive trends, accelerated since the passage of George W. Bush’s No Child Left Behind law in 200l and continued after Obama’s Race to the Top initiative:
• Deep budget cuts to traditional public schools; nationwide, more than a quarter million staffers and administrators, including 150,000 teachers were cut between 2010 and 2012 (1)
• Increased emphasis on privatization, including charter and online schools
• Dedication to required testing to evaluate student achievement as well as the performance of principals and teachers
• Increasing numbers of principals and teachers being fired for not meeting testing goals, especially in schools and school districts in lower socio-economic areas
• Teaching to the test has become the norm, with widespread cheating involving teachers and administrators.
• Increasing division along social-economic and racial lines between predominantly white charter schools and mostly black/minority public schools
• Transfer of resources from public schools to for-profit charter and online schools
• Almost two-thirds of the nation’s school districts were providing fewer dollars per student in 2012 than they had in 2008.
• More than 100 school districts, many in rural areas, cut the school week to four days, with almost one-half of school districts in California cutting back on art, drama, and music programs.
• Continued attacks from the right on teachers, their unions, and the problems of public education while promoting private alternatives
• Despite the policies of No Child Left Behind and the Race to the top, the U.S continues to fall behind in international student rankings.(2)
I am nearing completion of my next book, How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans, due out in January 2015. It will be a five-year evidence-based assessment of the Affordable Care Act (ACA). To be fair, the ACA does bring about some improvements, such as providing for children to stay on their parents’ health insurance until age 26, prohibiting exclusions based on pre-existing conditions, establishing government-sponsored exchanges to allow the uninsured to shop for coverage, and expanding Medicaid (at least in those states that agree to expansion). Almost 8 million people have gained coverage on the exchanges (though only 57 percent of them were previously uninsured) and about 7 million people have new Medicaid coverage. Despite these gains, however, there is a long list of problems that won’t be solved by further implementation of the ACA, including these:
• Access to care is still very limited for many millions of Americans, even if “insured”, and at best, there will still be 31 million uninsured in 2019.
• Costs of care continue to soar, especially as hospital systems expand and consolidate, thereby gaining increased market shares in their areas.
• There are no price controls throughout a largely private, for-profit delivery system.
• Private insurers are still in charge, gaming the system in new ways, such as establishing narrow networks of physicians and hospitals and marketing plans of low actuarial value.
• Many insurance policies now have annual deductibles more than $5,000 for individuals and $10,000 for families, forcing many people to forego necessary care because of cost.
• New pay-for-performance (P4P) initiatives have not improved quality of care, and there is widespread gaming of the reimbursement system to increase payments to physicians and hospitals.
• Cross-national studies of access, efficacy, quality and equity of care in the U.S. continue to be near the bottom by most measures in comparison with 10 other industrialized countries.(3)
• Patients have decreased choice of health care provider and hospital, as well as less continuity of care.
• Morale among physicians and other health care professionals is declining under the burden of increased administrative bureaucracy.
• Tiering of health care is increasing by ability to pay, not by medical need.(4)
These big changes in public education and health care in the U.S. over recent years have much in common. These are some of the parallels that raise serious concerns about where to go in the future:
• We are seeing erosion of access and quality in public education and health care, that will place many middle class and lower income Americans at a disadvantage, especially as income gaps continue to widen in our society. Legislation has been driven by corporate and private interests, leading to increasing privatization in both of these fields.
• The power of money in politics, bolstered by the Citizens United decision of the U.S. Supreme Court and the lack of campaign financing reform, has led to these predictable outcomes.
• Federal and state policies in public education and health care have both been driven by unproven or even discredited premises, such as—in education that “private must be better” and that “public school teachers are the problem,” and in health care that “private is more efficient,” and that “patients are the cause of increasing costs through overutilization” (moral hazard).
As a result of these policies in recent years, new norms have become established that do not work in the public interest. In public education, teaching to the test has become the rule, with firings of teachers and principals who do not meet arbitrary performance goals, ignoring the fact that socio-economic factors, such as poverty, play a big role in test results. The same holds true in health care, with physicians serving lower socio-economic groups having worse patient outcomes than those practicing in more affluent communities. Quality of teaching, as with quality of health care, worsen in such areas, despite the best efforts of dedicated teachers and health professionals. Instead of being rewarded for such service, they are punished by misguided approaches intended to gain “efficiency,” “cost containment,” and “improved quality,” but instead bring new profits to private interests at the expense of the public good.
Bob Herbert brings us this helpful insight about where we now find ourselves:
America’s increasingly stratified education, civic, and social
hierarchies will have to be modified. The great imperative of our time
is to imagine what that newer, fairer version of America would be
like and then to begin the very difficult work of creating it.”(5)
1. U.S. Bureau of Labor Statistics, Occupational Employment Statistics Surveys, 2010-2012.
2. Herbert, B. Losing Our Way: An Intimate Portrait of a Troubled America. New York. Doubleday, 2014, pp. 124-145.
3. Davis, K, Stremikis, K, Squires, D et al. Mirror, Mirror on the Wall: 2014 Update: How the U.S. Health Care System Compares Internationally. The Commonwealth Fund, June 16, 2014.
4. Geyman, JP. How Obamacare Is Unsustainable: Why We Need a Single-Payer Solution for All Americans.Friday Harbor, WA. Copernicus Healthcare, 2015.
5. Ibid # 2, p. 248.
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.
This Is How the New GOP Senate Will Try to Dismantle Obamacare
By Jonathan Cohn
New Republic, November 4, 2014
Most Republicans know that they can’t repeal Obamacare anymore. They’ll start with a symbolic vote for outright repeal. From there, (Ted) Cruz says, Republicans will go after Obamacare provisions “one at a time.”
Here’s what the GOP has in mind, based on conversations with health care experts and lobbyists:
- Repealing the individual mandate
- Repealing or modifying the employer mandate
- changing the threshold to 40 hours
- could propose raising (50 employee requirement) to 100 full-time employees
- Eliminating “risk corridors”
- Repealing the device tax
- Abolishing the Independent Payment Advisory Board (IPAB)
- Introducing “Copper Plans”
- 50 percent actuarial value
New Republic’s Senior Editor Jonathan Cohn, an astute and very well-informed observer of the health care reform scene, provides us with a quite plausible response of the new Republican majority in the next session of Congress. They will likely fulfill their promise to introduce legislation to repeal the Affordable Care Act (ACA), though knowing that the effort will end with either a filibuster or a presidential veto. The real action will take place over individual provisions of ACA.
Some of the less objectionable measures they propose could be included in other bills as part of the legislative compromise process. Other less desirable changes could avoid filibuster by being tacked onto reconciliation bills, and avoid veto by being added to must-sign bills ((e.g., bills to prevent shutting down the government).
Since the Republicans have never formed a consensus on the replace part of repeal and replace, it is unlikely that they will try to enact some of their proposed measures such as eliminating the tax preference of employer-sponsored plans, or selling plans across state borders to avoid effective regulatory oversight. Such efforts would create new problems that would be unpopular – not an approach they would likely take when they have their eye on the White House in two years.
So how does single payer activism fit into all of this? With one caveat, there should be no change in our mission to educate our colleagues and the public on a vastly superior alternative – a single payer national health program. As patients experience the deficiencies of our current dysfunctional system, they have to understand that it doesn’t have to be this way – that everyone can have their choices in essential health care without having to negotiate financial barriers to that care.
During the next session of Congress, it is clear that we will not see any movement on single payer legislation. Even if a wave of Republican Enlightenment were to flood Congress and they decided that single payer really was the preferred model, they would not allow President Obama to receive any credit by signing the bill, but rather would wait until a Republican President took office in 2017. Lest this seem like a fantasy, F.A. Hayek supported “a comprehensive system of social insurance.”
Our education process is two-fold: 1) describing the very positive features of the single payer model, and 2) exposing the severe inequities and deficiencies of our fragmented system which has only been perpetuated by ACA. The former is obvious, but the caveat applies to the latter.
Until we can move forward on single payer, it is important to take care of what we do have. We should not criticize the efforts of those who are still in the process of implementing ACA. They are doing the best they can under current laws and regulations. If Congress tries to enact measures that are clearly detrimental we should join our friends in opposing such actions. If beneficial patches to ACA are proposed, we should not oppose them merely because they perpetuate ACA, but rather support them as transitional improvements until we can achieve single payer.
But this is where we have a problem. We need to let the public know why these measures are inadequate – how they merely perpetuate our highly flawed system. But we must make a clear distinction between our efforts to make our health care system work well for everyone and the efforts of some members of Congress who would destroy as much of ACA as they can, and walk away leaving too many people exposed to yet more health and financial insecurity. When we are accused of helping the enemy of reform by opposing ACA we have to correct that misperception by letting them know that we support ACA as a transitional program that provides some relief until we can enact single payer, but that we cannot accept decades of incremental changes to ACA that can never lead to a rational, comprehensive system of health care financing.
Based on the simplistic messages that carried the election, it is obvious that we have a formidable task ahead of us. Our messages are not simple, but they need to be clear. Everyone can have affordable, high quality health care, but we do not have that with ACA nor would we with the anticipated Republican actions. We have to let people know.
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.
Some ObamaCare patients with high deductibles turning to community care centers
By Jim Angle
Fox News, November 4, 2014
When ObamaCare patients learn their deductible is so high they’re unlikely to get any reimbursement, they often wind up in places like the Denton, Texas Community Care Center.
“There are quite a few, and I saw another one today, where their deductibles are so elevated that they can’t afford them,” said Dr. Flippo Masciarelli, chief physician at the center, which was designed to treat indigent patients.
Robert Laszewski of Health Policy and Strategy Associates noted, “You’re going to the doctor, you’re paying (a) premium, and because of this really high deductible, you’re not getting any benefits.”
The administration pushed insurance companies to keep premiums low, but that also created high deductibles, about $5,000 per person for the least expensive plan, as well as narrow networks of providers.
But most people buy based only on premiums.
“They don’t even look at what their deductible is going to be,” said Dan Mendelson, CEO of Avalere Health. “They don’t look at the cost of the medications that they’re on. And they don’t look at the…network that they have.”
Masciarelli said,”one of the ladies we saw said she called eight primary care offices before she found us…” The rest would not treat people on her plan.
If the doctor these patients find orders additional tests or treatment, even those with ObamaCare are sometimes forced to go without.
Health economist John Goodman said, “They go to community health centers because it’s free or almost free and or very low charges. And that’s why they’re doing it. So they were coaxed to go into the ObamaCare system, they’re paying premiums over there. And now they’re asking what did I get for my premium? I’m having to go outside the system to get health care.”
Masciarelli agreed. “We do get asked that question at times, yes, wondering you know, I have this product. I can’t even use it. ”
Although this is a typical Fox News anecdotal report not based on any scientific study and designed to discredit “ObamaCare,” nevertheless it does make a very valid point. People obtaining their coverage through the insurance exchanges are finding that, with the narrow networks and high deductibles, they “can’t even use” their plans.
Fortunately these patients do have the backup that the 30 million people who will remain uninsured have – community health centers. But they will still have impaired access to specialized services because of unaffordable cost sharing, and because of a lack of specialists who are willing to provide services through the community health centers.
Although these plans do provide coverage for catastrophic events, it is primarily the providers rather than the patients who benefit. Because of EMTALA regulations, the patients would receive the care anyway, but the providers will be paid rather than having to write the care off as a loss. It is just one more example of how the system was designed to take care of the medical-industrial complex rather than placing the patient at the pinnacle.
Single payer would get rid of the narrow networks and unaffordable cost sharing, so no patient would be rejected based on the limitations imposed by the private insurers. But then that would deprive Fox News of these anecdotal reports that they use to bash President Obama. So what is our priority here?
A Little Knowledge Is a Risky Thing: Wide Gap in What People Think They Know About Health Insurance and What They Actually Know
By Kathryn A. Paez and Coretta J. Mallery
American Institutes for Research, October 2014
Health insurance is among the most complicated and costly products that consumers buy. Lacking health insurance-related knowledge and skills — or health insurance literacy — puts people at risk of choosing an insurance product that could fail to provide needed benefits or protect them financially.
More than half of all people surveyed were moderately or very confident in their ability to choose and use a health plan that is best for their family, but their actual knowledge was less.
Because many people believe they know more than they do about health insurance, they may not fully understand their options before committing to a particular health plan for an entire year, or they may have an unpleasant surprise when they use health care services and end up owing a larger amount out of pocket than expected.
Understanding Plan Type and Calculating Cost Sharing
When comparing and selecting health plans, 61 percent of people said they were moderately or very confident that they could choose the best health plan for themselves. Only 23 percent could identify characteristics of a preferred provider organization (PPO) — for example, “you may have to pay a percentage of the bill.”
Three out of four people said they were moderately or very confident that they have the knowledge to use health insurance. However, only 20 percent could accurately calculate how much they would pay for a visit to an in-network doctor when presented with a cost-sharing scenario that included a copayment, deductible and coinsurance.
Skills Differ by Age, Care Use, Race, Income, Education
Generally younger people were less health-insurance literate — for example, people aged 22 to 34 got an average of 55 percent of knowledge and skills items correct.
Likewise, people who use health care less frequently had more difficulties.
Health insurance knowledge and skills also varied greatly by race, with blacks and Hispanics on average having less knowledge about health insurance.
Knowledge and skills also decreased with income and education.
Choosing and using a health insurance plan can be daunting, especially for people with little experience with the health care system and health insurance. According to the 2013 AIR Health Insurance Literacy Survey, many Americans are unprepared to make informed choices when selecting and using health plans — especially younger people, minorities, people with lower incomes and those with less education.
At the same time, health insurance and benefit structures are becoming even more complex. As mentioned previously, consumers likely don’t need to know the exact differences between an HMO and PPO, but they do need to consider important health plan characteristics — such as patient cost sharing, which hospitals and doctors are in network, and the rules for out-of-network coverage — when choosing a plan.
Without efforts to increase health insurance knowledge and skills, many insured people will remain at risk of forgoing needed care if they don’t understand how their health insurance works or how to estimate out-of-pocket costs.
At a minimum, counseling efforts could stress that once people are enrolled, they should contact their health plan member services department to get questions answered.
Great. The insurance exchanges established by the Affordable Care Act have created a shoppers paradise for health insurance. People can choose from different premiums, different plans, at different levels of coverage, with different benefits, and different cost-sharing deductibles, co-payments and coinsurance, with different networks of physicians and hospitals, and different rules on out-of-network coverage, not to mention different insurance structures such as PPOs, HMOs, EPOs, and ACOs, whatever they are.
How many times have you heard physicians, nurses, health policy wonks, and knowledgeable others say that they have trouble figuring out their own insurance plans. Most end up waiting until they receive their Explanation of Benefits to find out just what was covered. How on earth can we ever expect people with little prior exposure to the intricacies of health insurance to be able to shop intelligently for plans offered in the exchanges? We can’t.
The tragedy is that poor choices in plan selection can have major impacts on both the physical and financial well being of the health plan purchasers. But when you think about it, virtually every plan offered has significant deficiencies, especially in limiting access through narrow networks and in increasing risk of financial hardship through excessive cost sharing. The subsidies may help some, but they are inadequate for most. Not only are the choices difficult to make, they are mostly all bad choices.
Those concerned about lack of “health insurance literacy” – an almost universal phenomenon – suggest that the solution is to increase transparency in the exchanges. But the authors of this report suggest that we need much more. Health insurance shoppers need additional training to “increase health insurance knowledge and skills.” Is that the answer?
What we want is a system wherein whenever we need health care, we go get it. Period. What we have is a conglomeration created by private and public intermediaries that make it difficult to decide where you can go when you need health care and how to pay for it ex-ante (premiums) and ex-post (cost sharing). And we end up paying much more for all of the administrative excesses that these intermediaries have created.
Do we want to make it all go away so that each of us can simply get the health care that we need? Easy – single payer.
The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks
By Jack S. Resneck Jr, MD; Aaron Quiggle, BA, MS; Michael Liu, BS; David W. Brewster, BA
JAMA Dermatology, October 29, 2014
In the evolving health insurance marketplace, many health plans have increasingly deployed “narrow networks,” reducing the number of contracted physicians or hospitals in a given metropolitan area. Whereas the use of these narrow networks in exchange plans offered under the Affordable Care Act (ACA) might have been expected given pressures to control costs and limit premiums, insurers have taken similar actions in several states to reduce the number of participating physicians in private plans offered as alternatives to Medicare patients known as Medicare Advantage (MA) plans.
Whereas some inaccuracies in ACA exchange plan directories may be expected given the novelty of those products in 2014 and the last-minute contracting that occurred, the MA marketplace is more mature and should have more stable physician listings. Accurate physician lists are particularly important at a time when MA plans are increasingly deploying narrow networks, making determinations of network adequacy critical for both primary care and many difficult-to-access specialties.
Using MA enrollment data from July 2014, we determined the 3 largest insurers in each of the 12 MSAs by enrollment.
A scripted telephone call was placed by one of us (A.Q. or M.L.) to each unique physician listing. All calls were placed during varied times of the day and days of the week for each MSA and occurred between August 5 and September 4, 2014.
He asked whether the listed physician accepts the relevant MA plan(s) and sees patients with itchy rashes and, if so, when the next available new-patient appointment was.
For the largest MA plans in the 12 MSAs… there were 4754 physician listings (4408 MDs, 346 DOs) meeting inclusion criteria.
Within health plans, a large number of these listings represented duplicates (2164 [45.5%]).
Among the 2590 remaining unique listings, there were many that our callers were unable to contact (464 [17.9% of unique listings]). Some of these were nonworking or wrong telephone numbers, and others were offices that reported that they had never heard of the listed physician. Several more (221 [8.5% of unique listings]) reported that the listed physician had died, retired, or moved out of the geographic area.
Many of the listed physicians whose offices we reached were not accepting new patients (221 [8.5% of unique listings]). There were also several who were subspecialized and were not willing to make an appointment for a patient with an itchy rash.
Fewer than half of listed physicians for each plan (1266 [48.9% of unique listings]) were reached, accepted the listed plan, and offered an appointment for a patient with an itchy rash. Because of the large number of duplicate listings, this translates to only 26.6% of individual directory listings being unique, taking the listed plan, and offering a medical dermatology appointment.
Wait times for the appointments offered by those listed physicians were relatively long (median, 30 days; mean, 45.5 days).
Our findings of inaccurate physician directories and long dermatology appointment wait times in many areas come at a time when many health plans are narrowing their MA networks by reducing the number of in-network physicians. There has been concern voiced about the proprietary methods that health plans are using to select physicians for termination and whether those methods themselves may limit access for patients with more costly health conditions. Our study cannot address those specific concerns, but our data do support the hypothesis that the large physician directories posted by many health plans exaggerate perceived access to dermatologists for MA patients. Furthermore, the long in-network appointment wait times observed for many of these plans suggest a lack of capacity that can only be exacerbated by further network narrowing.
One of the more alarming trends in health insurance innovation is the increasing use of narrower provider networks. Patients are losing their choice of their health care professionals and hospitals. Not only can this result in impaired access and longer wait times, it also can unfairly benefit the insurers by discouraging sicker patients from enrolling because of concerns about being unable to access the care that they need – especially specialized services.
This study looked at provider lists of dermatologists offered by a representative group of major private Medicare Advantage plans. Although the plans offered in the new insurance exchanges under the Affordable Care Act can plead being victims of transitional logistical complexities causing errors in their network lists, the private Medicare Advantage plans have been around for many years in an expansionary market and thus should represent the best of network administration. So how are they doing?
This study was completed less than two months ago and thus represents the current state of the art. When contacted, only one-fourth (26.6%) of the total number of dermatologists listed in the Medicare Advantage provider networks offered new appointments, and the mean wait time was 45 days. Only one-fourth! And with a 45 day wait!
This narrow network thing has really caught on. Some of these same Medicare Advantage plans are now cutting more providers from their networks, including dermatologists. And the newer ACA exchange plans are starting out with even narrower networks.
How can this benefit patients? Take away choice? Hiding true providers in otherwise worthless lists? Moving patients further back in the queues? And they want to give us more of this?
Traditional Medicare doesn’t have any networks. They are a creation of the private insurance industry, designed to serve their own nefarious interests. Enough! Time to get rid of them and enact an improved Medicare that takes care of all of us.
Another whistleblower suit alleges Medicare Advantage fraud
By Fred Schulte
The Center for Public Integrity, October 29, 2014
A new whistleblower lawsuit accuses a California health care firm of diagnosing “false and fraudulent” medical conditions that several Medicare Advantage plans allegedly used to overcharge the federal government by $1 billion or more.
The suit was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services, Inc., or MedXM. The Santa Ana, California-based firm sends medical professionals to the homes of Medicare Advantage members to assess their health.
The suit also names four Medicare Advantage insurance plans which, Silingo alleges, “turned a blind eye” to the practices. The health plans named in the suit are: Molina Healthcare of California; WellPoint, Inc., which operates Anthem Blue Cross and Blue Shield; Health Net of California, Inc. and Alameda Alliance for Health. None would comment.
MedXM chief executive officer Sy Zahedi called the allegations “categorically not true.”
Critics argue that federal officials waste billions of tax dollars every year by failing to crack down on health plans that game the arcane payment system. At least five other whistleblower cases accusing Medicare Advantage of fraudulently inflating risk scores are winding through federal courts, records show.
The four health plans “turned a blind eye to the truth” because the MedXM health assessments made them money, according to the suit. Medicare Advantage plans argue that the in-home health assessments can help members stay fit and in their homes as long as possible by spotting untreated diseases and dangerous living conditions. While the doctors and nurses don’t offer any treatment during their visit, they report their exam findings to the patient’s primary care physician.
But home visits also are controversial, largely due to their impact on Medicare costs.
The lawsuit names nearly 70 nurse practitioners and physician assistants whom she claims were not properly supervised by doctors. Some evaluations were conducted over the phone rather than in person, as required by federal regulations. In other cases, Silingo alleged, medical coders directed the health professionals to “modify” medical records “in order to increase the severity of the patients’ diagnosis.”
Some doctors and nurses were scheduling 20 to 25 of the home visits per day. The suit names three doctors whom it says scheduled at least 20 of the visits in a single day.
In December of 2012 about 750 Molina patients had “identical vital statistics for age, weight, sex height, blood pressure and heart rate” as well as similar medical findings, all done by the same doctor.
That doctor was “routinely” completing more than 22-25 assessments per day “traveling over a wide geographic area making it implausible that he actually performed the work that he claimed,” according to the suit.
Assuming the allegations of this lawsuit prove to be true, it appears that private Medicare Advantage insurers contracted with a private company that hired health care professionals to do in-home health assessments, not for treatment purposes but merely to collect data that, combined with innovative coding, could be used to increase government payments based on inflated risk scores.
These questionable visits were not only useful for increasing profits, they also served as a marketing tool in which the plans could claim that they were providing “coordinated care” not available in the traditional Medicare program, even if these visits were not much more than a sham.
It was already known that private Medicare Advantage insurers were gaming risk scores to increase profits. The revelation in this lawsuit demonstrates one of the mechanisms apparently used to cheat the Medicare program.
Medicare Advantage plans are paid more yet take away choice by limiting care to provider networks. So why do people enroll in them? It is primarily because of the lower cost sharing of the plans that have premiums that are much lower than the Medigap plans, which also offer similar cost sharing reductions. To reduce out-of-pocket spending, Medicare Advantage plans take away choice and Medigap plans charge excessive premiums.
If the same out-of-pocket cost reductions were rolled into the traditional Medicare program then patients could receive the same level of benefits as in Medigap or Medicare Advantage, while preserving free choice of hospitals and health care professionals. Even better, if the other flaws in Medicare were also fixed then we could use it for health care coverage for everyone – an improved Medicare for all.
Correction: State No Longer Looking to Administer Medicare
By Anne Galloway
VTDigger, October 26, 2014
Two recent stories about the relationship between Medicare and Green Mountain Care, the state’s planned universal publicly financed health care program – often called single-payer – were inaccurate. The stories were based on statutes on the Legislature’s website that had not been updated.
Section (e) of chapter 18, Public Private Universal Health Care System, in Title 33, Human Services, still states online that, “The Agency shall seek permission from the Centers for Medicare and Medicaid Services to be the administrator for the Medicare program in Vermont. If the Agency is unsuccessful in obtaining such permission, Green Mountain Care shall be the secondary payer with respect to any health service that may be covered in whole or in part by Title XVIII of the Social Security Act (Medicare).”
Act 144, which was enacted in 2014, repeals that section, though the statutes have not been updated online.
Section (f) of the same chapter now reads, “Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.”
State officials have said they are no longer seeking to administer Medicare as part of Green Mountain Care, and the law reflects that change.
It is currently unknown what Green Mountain Care will cover or what private supplemental health insurance policies will be offered once the program is in place.
Gov. Peter Shumlin has said there is no reason to expect that currently available supplemental coverage options for Medicare would change if the state moves forward with a single-payer health care system.
Vermont Act 144
An act relating to miscellaneous amendments to health care laws.
Sec. 1 Principles for Health Care Financing
(3) As provided in 33 V.S.A. § 1827, Green Mountain Care shall be the payer of last resort for Vermont residents who continue to receive health care through plans provided by an employer, by another state, by a foreign government, or as a retirement benefit.
Sec. 2 Vermont Health Benefit Exchange
(4) To the extent permitted by the U.S. Department of Health and Human Services, the Vermont Health Benefit Exchange shall permit qualified employers to purchase qualified health benefit plans through the Exchange website, through navigators, by telephone, or directly from a health insurer under contract with the Vermont Health Benefit Exchange.
Sec. 6 Administration; Enrollment
(f) Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.
Governor signed bill: May 27, 2014: http://www.leg.state.vt.us/docs/2014/Bills/H-0596/ACT0144%20As%20Enacted…
Green Mountain Care: http://www.greenmountaincare.org/vermont-health-insurance-plans
Vermont Health Connect: http://info.healthconnect.vermont.gov/healthplans
Shumlin Won’t Pursue Single Payer If It Doesn’t Help Economy
By Bob Kinzel
VPR, September 12, 2014
Act 48, the law that put Vermont on the path to a single-payer health care system, was passed in 2011. It called on the governor to unveil a single-payer financing plan in January of 2013.
That didn’t happen because Shumlin said he needed more time to develop a plan. Shumlin said he would be ready to release his proposal in January of this year.
But Shumlin missed this deadline as well. He now says he’ll unveil his plan at the start of the Legislative session in January.
Shumlin says there’s no point pursing a single-payer option if the effort will hurt the state’s business community.
“If we come up with a financing plan that doesn’t grow jobs, economic opportunity, and make Vermont more prosperous, trust me, we’re not going to do it,” said Shumlin.
Many consider Vermont to be the trailblazer for a state single payer program, serving as a model for other states to enact single payer reform. Vermont does have lessons for the rest of us. Let’s see what they are so far.
Green Mountain Care is Vermont’s program for Medicaid and for Dr. Dynasaur (Vermont’s Medicaid program for children and pregnant women). Most participants are now required to enroll in PC Plus – a Medicaid primary care managed care program. Vermont Health Connect is Vermont’s health insurance exchange (marketplace) under the Affordable Care Act through which individuals and small businesses can purchase insurance. Many Vermonters still have access to other programs such as Medicare, employer-sponsored health plans, retiree plans, and federal employee programs such as FEHBP and Tricare. So far this is not really much different than programs in other states – certainly far from single payer.
What about Medicare? Vermont has given up on attempting to become the administrator of Medicare, much less rolling Medicare funds into a universal single payer program. Gov. Peter Shumlin has even stated that “there is no reason to expect that currently available supplemental coverage options for Medicare would change.” Thus apparently they are continuing even the private Medigap supplements and private Medicare Advantage plans.
What about Green Mountain Care – the Medicaid program that was to be the single payer for Vermont? A few months ago legislation was signed by Gov. Shumlin that stated, “Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.” Further, “Green Mountain Care shall be the payer of last resort for Vermont residents who continue to receive health care through plans provided by an employer, by another state, by a foreign government, or as a retirement benefit.” At this point in time, that does not look like a program that is being remodeled to fulfill the role of a single payer.
The original Vermont legislation called on Gov. Shumlin to unveil a single payer financing plan in January, 2013. He missed that deadline and again missed the next one in January, 2014. He now says that he intends to release a plan in three months. We will have to wait to see what that proposal is, but at this late stage he is saying, “trust me, we’re not going to do it,” if the effort will hurt the business community. That seems quite tenuous for having worked on it a couple of years.
Many still talk about the enabling ACA waiver that Vermont will obtain in 2017, but the ACA section 1332 waiver applies only to the subsidies and some specific requirements of ACA. Even combined with Sec. 1115 Medicaid waivers and waivers for Medicare demonstration programs, especially considering the ERISA barriers, we simply do not have enough leeway for states to independently establish their own bona fide single payer systems.
The point is that we must have comprehensive federal legislation if we wish to establish state-level single payer systems. We need need the federal funds currently used in other federal health programs such as Medicare and Medicaid, and we need relief from federal statues and regulations such as ERISA. It would be far better to simply enact a national single payer program, but those who wish to pursue a state model must still advocate for comprehensive federal legislation.
Regardless, we can have single payer if we all work together to create the momentum for federal legislation, state and/or national, but none of us will see single payer if we each confine our activities to our respective states. Many have called for a cooperative effort. This is it!
Section 1557 of the Patient Protection and Affordable Care Act
U.S. Department of Health and Human Services
Section 1557 is the civil rights provision of the Affordable Care Act. Section 1557 prohibits discrimination on the ground of race, color, national origin, sex, age, or disability under “any health program or activity, any part of which is receiving Federal financial assistance … or under any program or activity that is administered by an Executive agency or any entity established under [Title I of ACA]….” Section 1557 is the first Federal civil rights law to prohibit sex discrimination in health care. To ensure equal access to health care, Section 1557 also applies civil rights protections to the newly created Health Insurance Marketplaces established under the Affordable Care Act.
Behind in Pay, Behind in Benefits
By Beth Umland
Mercer, October 17, 2014
It’s well known that working women earn less money than their male counterparts, but they may also be at a disadvantage when it comes to health benefits. Using data from Mercer’s National Survey of Employer-Sponsored Health Plans, we compared companies with workforces that are 65% female or more to those with workforces that are 65% male or more. About half of the mostly female companies are in health care and about a quarter are in the services sector, while mostly male companies are found predominately in manufacturing. The percentage of employees in collective bargaining agreements is about the same for the two groups, at just under 15%. Not surprisingly, when the workforce is mostly female, the average salary is about $10,000 less than when the workforce is mostly male.
Pay and benefits tend to go hand in hand. The health benefits at organizations with predominantly female workforces are also less generous than in those with predominantly male workforces. Because women generally use health services more than men, the disparity in benefit levels has an even greater financial impact. Women use maternity services, and childbirth, the leading cause of hospitalization in the US, accounts for a quarter of all hospital stays. We found that average employee contributions as a monthly dollar amount are higher in mostly female companies: For coverage in a PPO, the most common type of medical plan, the monthly contribution for family coverage is 31% higher. In addition, average in-network and out-of-network deductibles and out-of-pocket maximums are consistently higher. For example, the average in-network PPO deductibles in mostly female companies are $727 and $1,614, respectively, for individual and family coverage, compared to $557 and $1,318 at mostly male companies.
And the benefit gap doesn’t end with active employment. Mostly male companies are also more likely to offer retiree medical benefits – 27% offer medical coverage to pre-Medicare-eligible retirees, compared to just 19% of the mostly female companies.
Currently, about a third (36%) of companies with mostly female workforces do not provide coverage to all employees working an average of 30 or more hours per week. They will be required to do so in 2015.
It’s shameful. Although the Affordable Care Act (ACA) specifically prohibits discrimination based on sex, employers are still able to provide plans that are based on the underwriting characteristics of their employees. This Mercer report compares workforces that are over 65% female with those over 65% male and shows that females receive less generous health benefits – paying 31% more for deductibles and 31% more for the premium contribution for family coverage.
This is a direct result of the fact that ACA was designed to perpetuate employer-sponsored health plans. Had Congress enacted a single payer national health program instead, not only would sex-based underwriting have been eliminated, the financing of the entire health care system would have been changed to an equitable system based strictly on ability to pay.
Female workforces are paid about $10,000 less than male workforces. Under single payer, their share of health care financing would have been less than for males, since income taxes are progressive. For men who might think it is unfair that women should pay less in health care taxes, they could help fix that by supporting pay equity.
Public Trust in Physicians — U.S. Medicine in International Perspective
By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero, M.P.H.
The New England Journal of Medicine, October 23, 2014
One emerging question is what role the medical profession and its leaders will play in shaping future national health care policies that affect decision making about patient care.
Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession’s views and leadership. But an examination of U.S. public-opinion data over time and of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a note of caution about physicians’ potential role and influence with the U.S. public.
In a project supported by the Robert Wood Johnson Foundation and the National Institute of Mental Health, we reviewed historical polling data on public trust in U.S. physicians and medical leaders from 1966 through 2014, as well as a 29-country survey conducted from March 2011 through April 2013 as part of the International Social Survey Programme (ISSP), a cross-national collaboration among universities and independent research institutions.
In 1966, nearly three fourths (73%) of Americans said they had great confidence in the leaders of the medical profession. In 2012, only 34% expressed this view. But simultaneously, trust in physicians’ integrity has remained high. More than two thirds of the public (69%) rate the honesty and ethical standards of physicians as a group as “very high” or “high” (Gallup 2013).
Today, public confidence in the U.S. health care system is low, with only 23% expressing a great deal or quite a lot of confidence in the system. We believe that the medical profession and its leaders are seen as a contributing factor.
This phenomenon does not affect physicians in many other countries. Indeed, the level of public trust in physicians as a group in the United States ranks near the bottom of trust levels in the 29 industrialized countries surveyed by the ISSP. Yet closer examination of these comparisons reveals findings similar to those of previous U.S. surveys: individual patients’ satisfaction with the medical care they received during their most recent physician visit does not reflect the decline in overall trust. Rather, the United States ranks high on this measure of satisfaction. Indeed, the United States is unique among the surveyed countries in that it ranks near the bottom in the public’s trust in the country’s physicians but near the top in patients’ satisfaction with their own medical treatment.
Part of the difference may be related to the lack of a universal health care system in the United States. However, the countries near the top of the international trust rankings and those near the bottom have varied coverage systems, so the absence of a universal system seems unlikely to be the dominant factor.
The United States also differs from most other countries in that U.S. adults from low-income families (defined as families with incomes in the lowest third in each country, which meant having an annual income of less than $30,000 in the United States) are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families.
In drawing lessons from these international comparisons, it’s important to recognize that the structures in which physicians can influence health policy vary among countries. We believe that the U.S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries. Moreover, the U.S. medical profession, unlike many of its counterparts, does not share in the management of the health system with government officials but instead must exert its influence from outside government through various private medical organizations. Moreover, in terms of health policy recommendations, the U.S. medical profession is split among multiple specialty organizations, which may endorse competing policies.
Nevertheless, because the United States is such an outlier, with high patient satisfaction and low overall trust, we believe that the American public’s trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation’s health and health care, even if doing so might be disadvantageous to some physicians. In particular, polls show that Americans see high costs as the most important problem with the U.S. health care system, and nearly two thirds of the public (65%) believes these costs are a very serious problem for the country. To regain public trust, we believe that physician groups will have to take firm positions on the best way to solve this problem. In addition, to improve trust among low-income Americans, physician leaders could become more visibly associated with efforts to improve the health and financial and care arrangements for low-income people. If the medical profession and its leaders cannot raise the level of public trust, they’re likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective.
Another unique feature of the U.S. health care system that sets us apart from other nations: “You just can’t trust doctors nowadays, but my doctor is really good.” What can we make of this?
In general, individuals are relatively satisfied with their personal care. Low-income individuals are less satisfied, but that is likely related to the deficient financing of their care and the consequences of that – a characteristic of our fragmented, dysfunctional system of financing health care. But, overall, our system is capable of ensuring patient contentment.
It is the confidence in physician leadership that has deteriorated. The authors of this article suggest some possible explanations, but it is more likely that the image of the profession at large has changed from that of the dedicated personal physician steeped in the Hippocratic tradition, to that of the high-tech, entrepreneurial agent of the medical-industrial complex. Combine that perspective with the very high costs of health care today – costly care which physicians orchestrate – and it is no wonder that the public is no longer as trusting of the profession. Only “my doctor” is immune to this.
When you look at the role that the AMA had in the enactment of the Affordable Care Act, it is evident that they were not there to represent patients; they were there alongside the other elements of the medical-industrial complex – especially the insurance, pharmaceutical and hospital industries – to be sure that they got their own share of the action. The only patient advocates present were the consumer organizations that chose the default option of “political feasibility,” becoming “strange bedfellows” of the private insurance industry.
There are many dedicated individual physicians and other health care professionals who clearly place patients first. They are well represented in organizations such as Physicians for a National Health Program. They are also well represented in the AMA and the various specialty organizations, but, as a collective voice, they are ineffective in communicating the tradition of caring; rather they passively communicate the acceptance of the medical-industrial complex – a very sterile advocacy position.
Let’s indulge in a fantasy. Let’s imagine that our professional organizations all joined together in a clarion call for comprehensive, affordable, high-quality care for absolutely everyone – including those low-income individuals who distrust the profession today. Single payer would bring us such quality that is truly affordable.
With a voice unified in support of the patient, what do you think would then happen to the level of confidence that the public has in the medical profession? Physicians would once again relish respect as a noble profession advocating for their patients. As an aside, it would also mean that they would have a very pleasant work environment and be adequately compensated for their efforts. If the system works for patients, it will work for physicians.
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