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.
Cost-Sharing Obligations, High-Deductible Health Plan Growth, and Shopping for Health Care
By Anna D. Sinaiko, PhD; Ateev Mehrotra, MD; Neeraj Sood, PhD
JAMA Internal Medicine, January 19, 2016
The rapid growth of high-deductible health plans (HDHP) has been driven in part owing to a belief that cost-sharing obligations (ie, having skin in the game) will encourage health insurance enrollees to shop for health care. The wide variation in costs across physicians and hospitals implies considerable opportunity for enrollees to save money by switching to lower-cost providers. High-deductible health plan enrollment is associated with lower health care spending. However, prior studies using health insurance claims data indicate these savings are primarily owing to decreased use of care and not because HDHP enrollees are switching to lower-cost providers. Limited prior work has assessed attitudes toward price shopping among HDHP enrollees and whether they were more likely to consider costs when seeking care.
We surveyed a nationally representative sample of insured US adults between 18 and 64 years of age who used medical care in the last year and compared HDHP enrollees with people in traditional plans on rates of shopping for care. The definition of an HDHP was established as a health plan having an individual deductible greater than $1250 or a family deductible greater than $25006 or a health plan that included a health savings account.
During their last use of medical care, HDHP enrollees were no more likely than enrollees in traditional plans to consider going to another health care professional for their care (n = 120 [10.9%] vs n = 85 [10.0%]; P = .67), or to compare out-of-pocket cost differences across health care professionals (n = 42 [3.8%] vs n = 23 [2.7%]; P = .37).
Simply increasing a deductible, which gives enrollees skin in the game, appears insufficient to facilitate price shopping. Members of HDHP and traditional plans are equally likely to price shop for medical care, and they hold similar attitudes about health care prices and quality.
High-Deductible Health Plans and Higher-Value Decisions
By Joseph S. Ross, MD, MHS
High-deductible health plans — insurance plans that have lower premiums but higher deductibles than traditional health plans — have been increasingly promoted as a means to incentivize higher-value health care decision making. However, we have little information on how individuals take accessibility, cost, and quality information into account when making health care decisions. Moreover, there remains uncertainty about whether individuals will obtain recommended health care services while at risk for greater out-of-pocket costs.
In this issue of JAMA Internal Medicine, Sinaiko and colleagues conduct an internet-based survey of enrollees in high-deductible health plans and traditional health plans to better understand how they think about health care decisions. Individuals enrolled in plans with different financial incentives actually share many of the same beliefs about health care pricing and how to obtain high-quality care. Both rarely consider obtaining care from a different health care professional and even less often compare costs among health care professionals. Despite the limitations of an internet-based sample and few questions to disentangle the nuance of decision making, an interpretation of this study could be that high-deductible health plans are rationally designed for individuals who do not yet have access to sufficient information to make higher-value decisions in today’s market, suggesting that these plans have not yet succeeded at making cost and quality information more available and more actionable for their enrollees. However, a more likely interpretation is that getting enrollees to make higher-value decisions remains a mirage. High-deductible health plans take advantage of an irrationally designed health care system. In fact, information about our health care system is asymmetric in that it is better understood by physicians and less so by patients, which means patients obtaining care are not truly informed decision makers.
It is true that high-deductible health plan enrollees have “skin in the game.” However, these enrollees are exposed to substantial out-of-pocket cost risk with little evidence that this risk exposure will incentivize higher-value health care decisions, meaning they are essentially playing the game blindfolded with one hand tied behind their back.
This study shows that individuals with high-deductible health plans (HDHP) are no more likely to select their care based on their out-of-pocket costs than do individuals enrolled in traditional health plans without high deductibles. As the editorial states, it is likely that “getting enrollees to make higher-value decisions remains a mirage.”So high deductibles do not cause patients to be smart shoppers, but they do cause patients to decline beneficial health care services. They also create financial hardships for some patients. Thus high deductibles have a net negative impact. We should get rid of them. A single payer system is a much more efficient and patient-friendly method of controlling health care spending.
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.
Transcript of the Democratic Presidential Debate
The New York Times, January 17, 2016
(The debate is sponsored by the Congressional Black Caucus Institute)
Hillary Clinton: We finally have a path to universal health care. We have accomplished so much already. I do not to want see the Republicans repeal it, and I don’t to want see us start over again with a contentious debate. I want us to defend and build on the Affordable Care Act and improve it.
Bernie Sanders: No one is tearing this up, we’re going to go forward. But with the secretary neglected to mention, not just the 29 million still have no health insurance, that even more are underinsured with huge copayments and deductibles. Tell me why we are spending almost three times more than the British, who guarantee health care to all of their people? Fifty percent more than the French, more than the Canadians. The vision from FDR and Harry Truman was health care for all people as a right in a cost-effective way.
Bernie Sanders: What this is really about is not the rational way to go forward — it’s Medicare for all — it is whether we have the guts to stand up to the private insurance companies and all of their money, and the pharmaceutical industry. That’s what this debate should be about.
Hillary Clinton: So, what I’m saying is really simple. This has been the fight of the Democratic Party for decades. We have the Affordable Care Act. Let’s make it work.
Health Reform Realities
By Paul Krugman
The New York Times, January 18, 2016
Obamacare is … what engineers would call a kludge: a somewhat awkward, clumsy device with lots of moving parts. This makes it more expensive than it should be, and will probably always cause a significant number of people to fall through the cracks.
The question for progressives — a question that is now central to the Democratic primary — is whether these failings mean that they should re-litigate their own biggest political success in almost half a century, and try for something better.
My answer, as you might guess, is that they shouldn’t, that they should seek incremental change on health care (Bring back the public option!) and focus their main efforts on other issues — that is, that Bernie Sanders is wrong about this and Hillary Clinton is right.
… as the health policy expert Harold Pollack points out, is that a simple, straightforward single-payer system just isn’t going to happen.
Here’s why creating single-payer health care in America is so hard
By Harold Pollack
Vox, January 16, 2016
The experience of peer industrial democracies suggests that a well-designed single-payer system would be more humane and markedly less expensive than what we have right now.
Passing a single-payer plan requires precisely the same interest-group bargaining and logrolling required to pass the ACA. The resulting policies will thus replicate some of the very same scars, defects, and kludge that bedevil the ACA.
Progressives should still push for basic reforms that improve our current system. I supported the public option in 2009. I still do. I hope it resurfaces in some form, particularly for older participants in the state marketplaces . It may open a pathway to a true single-payer. If it doesn’t — which I suspect it will not — it might still provide a valuable alternative and source of pricing discipline within our pathological health care market.
Bernie Sanders’s single-payer plan isn’t a plan at all
By Ezra Klein
Vox, January 17, 2016
Sanders calls his plan Medicare-for-All. But it actually has nothing to do with Medicare. He’s not simply expanding Medicare coverage to the broader population — he makes that clear when he says his plan means “no more copays, no more deductibles”; Medicare includes copays and deductibles. The list of what Sanders’s plan would cover far exceeds what Medicare offers, suggesting, more or less, that pretty much everything will be covered, under all circumstances.
Behind Sanders’s calculations, both for how much his plan will cost and how much Americans will benefit, lurk extremely optimistic promises about how much money single-payer will save. And those promises can only come true if the government starts saying no quite a lot — in ways that will make people very, very angry.
This is what Republicans fear liberals truly believe: that they can deliver expansive, unlimited benefits to the vast majority of Americans by stacking increasingly implausible, and economically harmful, taxes on the rich. Sanders is proving them right.
Why We Can’t Wait
By Martin Luther King, Jr.
“For years now, I have heard the word ‘Wait!’ It rings in the ear of every Negro with piercing familiarity. This ‘Wait’ has almost always meant ‘Never.’ We must come to see, with one of our distinguished jurists, that ‘justice too long delayed is justice denied.’”
Martin Luther King, Jr. already said it, and that was half a century ago.
[PNHP note: Physicians for a National Health Program is a nonpartisan educational organization. As a consequence, it neither supports nor opposes any candidate for public office.]
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.
The single-payer debate we should be having
By Matthew Yglesias
Vox, January 15, 2016
Bernie Sanders’s argument in favor of single-payer health care is pretty simple.
“The United States is the only major nation in the industrialized world that does not guarantee health care as a right to its people,” Sanders said at a 2015 rally of the National Nurses Union, one of the leading advocacy groups in favor of moving to a Medicare-for-all approach. “Meanwhile, we spend far more per capita on health care with worse results than other countries. It is time that we bring about a fundamental transformation of the American health care system.”
Hillary Clinton’s campaign has sought to counter the appeal of this proposition with a questionable line of attack, arguing that the election of a Democratic president on a Medicare-for-all platform would somehow help Republicans unwind the existing Affordable Care Act and other aspects of insurance provision.
Alternately, she has (accurately) noted that a universal Medicare system would require higher taxes — only to be met with the counter that a universal Medicare system would involve less overall spending.
On this, too, Sanders is right. Medicare manages to finance patients’ health care at dramatically lower per-person rates — just as foreign countries do — so if Medicare covered everyone, total spending would decline even as some of it was shifted to the tax side of the ledger.
The real issue is something else entirely. Single-payer systems save money by squeezing health care providers — doctors, hospitals, and ultimately everyone who works for them — which would be very difficult to accomplish ex post facto. If the political consensus did exist for enacting large, across-the-board cuts in doctors’ fees and hospital charges, then there would be no need to shift to a single-payer system in order to accomplish the cuts. In the absence of such a consensus, the switch to single-payer actually wouldn’t save money, and the costs would become exorbitant.
Medicare works because it pays providers less
Why would a government-run system be more efficient?
Well, here’s the answer: Foreign single-payer systems pay doctors less. They also pay pharmaceutical companies less. They pay less for medical devices, too.
It turns out that Medicare uses this trick, too, offering doctors only about 80 percent of what private insurance plans pay them.
But to the average health care provider, the Medicare patient market is just too big to ditch. Doctors — and hospitals and everyone else — take what they get and are glad for it.
A single-payer structure is neither necessary nor sufficient
The thing about saving money by having a single health care payer squeeze providers on reimbursement rates is that adopting a single-payer structure is neither necessary nor sufficient to achieve the gains. In other words, if the American political system wanted to cut doctors’ payments, we could do that without moving to a single-payer system. Conversely, adopting a single-payer system does not on its own lead to low reimbursement rates — that’s a separate decision that the political system would have to make.
The truth is that there are two entirely separate questions: Who pays health insurance claims, and what prices does the government set? It’s true that shifting from a multi-payer to a single-payer system streamlines some elements of payment administration, but the overwhelming preponderance of the cost savings in a Medicare-for-all plan comes from the lower reimbursement rates.
To get single-payer, liberals have to be more honest with themselves
But if they ever want to get such a bill passed, liberals are going to have to start being more honest with themselves about what their vision entails — a sharp 20 percent cut in doctors’ pay rates, alongside comparable cuts for other kinds of health care providers.
Right now, Sanders and other single-payer proponents’ main strategy for dealing with this problem is to talk around it. Medicare is extremely popular, so “Medicare for all” is a popular slogan, and that’s what they talk about. But you can’t get major policy change enacted on this basis. At some point, to get the savings of their dreams liberals are going to need to win a straightforward argument over the merits of cutting doctors’ pay.
But in my experience, relatively few rank-and-file single-payer proponents are even aware that stingy reimbursements is how single-payer controls costs — in part because essentially none of the movement’s leaders ever say it publicly.
Matthew Yglesias tells us that “the overwhelming preponderance of the cost savings in a Medicare-for-all plan comes from the lower reimbursement rates,” thus “adopting a single-payer structure is neither necessary nor sufficient to achieve the gains.” He then criticizes single-payer proponents for not stating this publicly. What Matt does not seem to understand about PNHP is that we are meticulous with our facts, so we would never state something that is so misleading as to be untrue.
A well-designed single payer system includes multiple features that contain health care spending. The most important is the administrative efficiency. Under the Affordable Care Act, the private insurance industry is allowed to keep 15 to 20 percent of the premiums for administrative services and profits. The administrative costs for Medicare are about two percent, and that includes costs of other government programs that support Medicare. Adopting an improved Medicare for all would eliminate much of the excess administrative waste of the private insurers.
On the provider side, our highly inefficient multi-payer system also places a tremendous administrative burden on physicians, hospitals and other providers. In fact, administrative work consumes about one-sixth of U.S. physicians’ time (while eroding their morale, precipitating burnout). U.S. physician practices spend nearly four times as much money interacting with health plans and payers as do their Canadian counterparts.
Administrative costs consume about 31 percent of total U.S. health care spending. That is about twice that of Canada – 16.7 percent. Much of that difference is due to the financing systems – single payer in Canada and a dysfunctional multi-payer system in the U.S. – and thus most of that portion would be recoverable if we switched to single payer.
Yglesias says that we would have to reduce physician payments by 20 percent to achieve the spending goals of a single payer system. But when Canada changed to single payer, not only were physicians’ incomes not harmed, they remain among the top earners in the country.
There are several other policies of a single payer system that control spending. Hospitals are placed on global budgets – a process that works well as demonstrated by public services such as our fire departments. Excess capacity in the delivery system drives up spending, but that can be controlled by regional planning and capital budgets. The prices of pharmaceuticals and medical supplies can be negotiated just as the VA Health system already does so quite successfully. A single payer system incentivizes primary care which has been shown to spend health dollars more efficiently.
The United States and Canada followed the same trajectory in health care inflation until they adopted the Canada Health Act, providing a single payer system in each province. Since then health care inflation has been less in Canada than in the U.S. Likewise, adopting single payer in the U.S. would truly bend the cost curve, putting us on a more sustainable trajectory. Merely cutting prices 20 percent would continue us on a parallel inflationary trajectory.
Of course, there are some other advantages of single payer, besides the cost savings, which would not be achieved merely by cutting prices 20 percent – like truly universal coverage, free choice of physicians and hospitals, removal of financial barriers to care, and better access through capital planning.
We know what we know, but we don’t know what we don’t know. Although Hillary Clinton finds it politically expedient to leave out crucial facts in her critique of single payer, I would assume that Matt Yglesias, as a journalist of high integrity (and for whom I have great respect), would welcome a more thorough understanding of PNHP’s single payer model. We hope he reads this. Then we can have that debate that we should be having.
If You Can’t Measure Performance, Can You Improve It?
By Robert A. Berenson, MD
JAMA Forum, January 13, 2016
“If you can’t measure it, you can’t manage it” is an often-quoted admonition commonly attributed to the late W. Edwards Deming, a leader in the field of quality improvement. Some well-respected health policy experts have adopted as a truism a popular variation of the Deming quote — “if something cannot be measured, it cannot be improved” — and point to the recent enactment of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) as a confirmation of “the broadening societal embrace” of this concept.
The problem is that Deming actually wrote, “It is wrong to suppose that if you can’t measure it, you can’t manage it — a costly myth” — the exact opposite. Deming consistently cautioned against requiring measurement to guide management decisions, observing that the most important data needed to manage often are unknown and unknowable.
Many Routes to Improvement
The requirement for measurement as essential to management and improvement is a fallacy, not a self-evident truth and not supported by Deming, other management experts, or common sense. There are many routes to improvement, such as doing things better based on experience, example, as well as evidence from research studies.
Comparative public performance using meaningful and accurate measures has led to quality improvements, as clinicians and hospitals reflect on their own comparative performance and seek to improve their public standing. Examples include improved hospital care for patients experiencing heart attacks and improved renal dialysis. In most clinical areas, however, we lack readily available measures to use as valid benchmarks to assess performance.
Not deterred, however, last year a rarely bipartisan Congress passed the MACRA legislation. Its core element was repealing the unsustainable sustainable growth rate mechanism threatening huge payment cuts to physicians caring for Medicare patients. The law called for development of “value based” payment approaches that would pay for quality and cost outcomes, rather than just for the myriad services physicians provide or order, whether or not the services are needed or well performed. “Paying for value, not volume” has become the slogan du jour, itself assuming a mostly unchallenged position in health policy circles.
Now comes the hard part: actually achieving greater value, rather than fashioning an increasingly complex, intrusive, and likely doomed attempt to measure value.
After the MACRA’s Merit-Based Incentive Payment System (MIPS) is fully phased in early in the next decade, a physician caring for Medicare patients under MIPS stands to lose up to 9% of their Medicare payments or conceivably gain 27%, based on their performance on measures of quality, their use of health care resources, the extent to which they have implemented electronic health records, and their participation in quality improvement activities.
But performance on a few, random and often unreliable measures of performance can provide a highly misleading snapshot of any physician’s value.
A Bad Idea?
Practical challenges aside, pay for performance for health professionals may simply be a bad idea. Behavioral economists find that tangible rewards can undermine motivation for tasks that are intrinsically interesting or rewarding. Furthermore, such rewards have their strongest negative impact when they are perceived as being large, controlling, contingent on very specific task performance, or associated with surveillance, deadlines, or threats, as with MIPS.
Another major problem with the current preoccupation with measurement as the central route to improvement is the assumption that if a quality problem isn’t being measured, it basically doesn’t exist. A prime example is diagnosis errors. Recently, an Institute of Medicine (IOM) committee, on which I was a member, issued Improving Diagnosis in Health Care, documenting serious errors of diagnosis in 5% to 15% of interactions with the health care system.
As the report emphasizes, we cannot now measure the accuracy of diagnoses, which means MIPS scores will not include performance on this core physician competency. Still, the IOM committee proposed numerous improvement strategies. These include development of immediate feedback programs to erring clinicians from patients and other health professionals when a serious misdiagnosis occurs (making errors memorable if not measureable), greater attention in medical education to the cognitive bias that commonly clouds clinicians’ judgment, improved systems to ensure that abnormal test results are promptly communicated to patients and diagnostic team members, and giving patients direct access to their medical records so they can introduce relevant, missing information and correct the misinformation that is common in clinical records.
These and other IOM recommendations represent better practices that might dramatically improve diagnostic accuracy, relying not on performance measures but on adopting better work processes and focused education. Measures would help, but substantial progress can be made regardless.
The overarching concern is that under MIPS and similar programs, physicians will focus on the money while their intrinsic motivation to make accurate, timely diagnoses as a core responsibility will be crowded out. If so, the worthwhile recommendations in the IOM report will likely sit on the shelf, gathering dust, thanks to the misguided supposition that “if you can’t measure it, you can’t manage it.”
CMS chief vows to replace meaningful use with better policy
AMA Wire, January 13, 2016
Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt on Monday said that the agency is changing its culture to focus more on listening to physician needs and giving them the freedom they need to keep patients at the center of the practice of medicine.
Referring to execution of the electronic health record (EHR) meaningful use program, Slavitt noted that the agency’s previous regulatory approach created difficulties. “When in doubt, I think, do less and figure it out.”
“The meaningful use program as it has existed will now be effectively over and replaced with something better,” Slavitt said.
In its place will be the new Merit-Based Incentive Payment System (MIPS), called for in the Medicare Access and CHIP Reauthorization Act of 2015, which is intended to sunset the three existing reporting programs and streamline them into a single program.
“The stakes are high for this program,” Slavitt said. “As any physician will tell you, physician burden and frustration levels are real. Programs designed to improve often distract. Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don’t get it.”
As several prior Quote of the Day messages warned, MACRA’s Merit-Based Incentive Payment System (MIPS) is a horrendous trade-off for getting rid of the flawed SGR payment system. At least for the next decade, we are going to have to live with a system which supposedly will reward or penalize physicians based on measured performance when “the most important data needed to manage often are unknown and unknowable.”
Robert Berenson writes, “a few, random and often unreliable measures of performance can provide a highly misleading snapshot of any physician’s value.” Further, under MIPS, “physicians will focus on the money while their intrinsic motivation to make accurate, timely diagnoses as a core responsibility will be crowded out.”
CMS is responding to the great dissatisfaction with the administrative burden of the “meaningful use” program for electronic health records, which would have been the source of many of these performance measurements. But what is their response? Acting CMS Administrator Andy Slavitt says, “The meaningful use program as it has existed will now be effectively over and replaced with something better” – MIPS! He says, “Done poorly, measures are divorced from how physicians practice and add to the cynicism that the people who build these programs just don’t get it.”
Well, yes. They just don’t get it.
Disentangling Moral Hazard and Adverse Selection in Private Health Insurance
By David Powell and Dana Goldman
National Bureau of Economic Research, January 2016
NBER Working Paper 21858
Moral hazard and adverse selection create inefficiencies in private health insurance markets and understanding the relative importance of each factor is critical for policy. We use claims data from a large firm to isolate moral hazard from plan selection. Previous studies have attempted to estimate moral hazard in private health insurance by assuming that individuals respond only to the spot price, end-of-year price, expected price, or a related metric. The nonlinear budget constraints generated by health insurance plans make these assumptions especially poor and we statistically reject their appropriateness. We study the differential impact of the health insurance plans offered by the firm on the entire distribution of medical expenditures without assuming that individuals only respond to a parameterized price. Our empirical strategy exploits the introduction of new plans during the sample period as a shock to plan generosity, and we account for sample attrition over time. We use an instrumental variable quantile estimation technique that provides quantile treatment effects for each plan, while conditioning on a set of covariates for identification purposes. This technique allows us to map the resulting estimated medical expenditure distributions to the nonlinear budget sets generated by each plan. We estimate that 53% of the additional medical spending observed in the most generous plan in our data relative to the least generous is due to moral hazard. The remainder can be attributed to adverse selection. A policy which resulted in each person enrolling in the least generous plan would cause the annual premium of that plan to rise by $1,000.
From the Introduction
Moral hazard and adverse selection create inefficiencies in health insurance markets and result in a positive correlation between health insurance generosity and medical care consumption. The policy implications are very different, however, depending on the relative magnitudes of each source of distortion, though isolating the independent roles of both moral hazard and adverse selection is rare in the health insurance literature. This paper separates moral hazard and adverse selection for the health insurance plans offered by a large firm.
The average observed expenditures in the most generous plan are $3,969 more than the per person costs in the least generous plan. We estimate that if selection were random, that the most generous plan would lead to $2,117 in more spending than the least generous plan, implying that 53% of the differential can be attributed to moral hazard. We also estimate adverse selection without restrictive structural assumptions. We find that if everyone in the sample were enrolled in the least generous plan that the premium for that plan would increase by over $1,000.
2.1 Moral Hazard and Adverse Selection
Optimal policy depends on the relative important of adverse selection compared to moral hazard in explaining the correlation between plan generosity and medical care costs. The policy implications for moral hazard are different than those required to confront adverse selection. Adverse selection typically requires risk-pooling, while distortions driven by moral hazard would motivate additional cost-sharing.
If we define attrition as individuals enrolled in 2005 but enrolled for less than 365 days in 2007, the attrition rate in the MarketScan data (selecting on firms in the data in both 2005 and 2007) is 58.3%. Our sample has a 58.7% attrition rate.
Understanding moral hazard and adverse selection in private health insurance is widely- recognized as critical to policy. While the literature has frequently estimated the effect of price on medical care consumption, it has typically resorted to parameterizing the mechanism through which individuals respond to cost-sharing. We show that these assumptions typically contradict economic reasoning, and we provide empirical evidence that these specifications perform poorly. In this paper, we estimate the impact of different health insurance plans on the entire distribution of medical care consumption using a new instrumental variable quantile estimation method. These estimated distributions are the distributions caused by the plans in the absence of systematic selection into plans. We map these causal distributions to the parameters of the plans themselves. We can statistically reject that individuals only respond to the end-of-year price.
We also estimate the magnitude of adverse selection. We find favorable selection in the least generous plan and adverse selection in the most generous. We estimate that adverse selection is responsible for $773 of additional per-person costs in the most generous plan, implying that an individual considering this plan would pay over $60 per month in additional premium payments simply to cover the expected costs of the population selecting into the plan. Similarly, a policy which resulted in our entire sample enrolling in the least generous plan would cause annual premiums for that plan to rise by over $1,000.
We estimate that moral hazard is responsible for 53% of the differences in expenditures between the most and least generous plans. Adverse selection also plays an important role, accounting for the other 47%. In the absence of moral hazard, the difference in average medical expenditures across these plans would be $2,117 instead of $3,969. Finally, we find that using the previous year’s medical expenditures as a metric of selection greatly overstates the magnitude of selection.
PDF of full paper (53 pages):
In health insurance, moral hazard occurs when individuals obtain more health care than they would have if it were not paid for by the insurer. Adverse selection occurs when individuals with greater health care needs select plans that provide greater coverage. Both have an impact on health care spending. This paper estimates the relative impact of each of these in spending under private health insurance.
Each is responsible for roughly half of the differences of expenditures between the most and least generous health plans. So enrollees in the more generous plans pay higher premiums because of both moral hazard and adverse selection.
Today’s standard in insurance coverage is shifting towards lower actuarial value plans – plans that pay a lower percentage of the total health care costs. What does this study tell us about premiums for these less generous health plans? As more people enroll in them, which they are, the premiums increase to cover the additional expenditures for those who otherwise would have enrolled in the more comprehensive plans. The lower actuarial value plans are subject to favorable selection (the healthy buying less expensive plans in anticipation of not needing care), but that diminishes as higher cost patients move from the more comprehensive plans into these cheaper plans.
The insurance actuaries set premiums based partly on anticipated moral hazard and adverse selection. Though less comprehensive plans theoretically have less moral hazard and no adverse selection, the lower premiums are attractive even to those with higher health care needs. As Powell and Goldman have shown, increased enrollment in the least generous plans cause premiums for those plans to increase. This likely goes a long way toward explaining why premium increases this year were much higher than the overall rate of inflation, even though the rate of increase in total national health expenditures has slowed.
Under a single payer national health program, adverse selection doesn’t even exist since everyone is in the same plan. Efficiency is an important goal of health care reform, and wouldn’t it be much more efficient putting these health economists to work designing a simple single payer financing system, instead of laboring over the complexities of making a dysfunctional and inequitable market of private health plans somehow work for us, though not very well?
Long-term care must become a more prominent part of the single-payer campaign
By Henry Moss, PhD
January 11, 2016
We are facing a perfect storm. AARP’s Public Policy Institute points out that as boomers age into their 80s, there will be a sharp drop in available family caregivers due to the “birth dearth” following the postwar baby boom. At the same time, longevity is increasing due to effective treatments of heart disease, lung disease, diabetes, cancer, and other conditions. A longer life, however, will likely mean more years with severe disability for boomers due to the secondary effects of increased obesity, including high blood pressure, high cholesterol, and inflammation due to metabolic disorders.
These secondary effects include damage to brain blood vessels and a likely increase in the incidence of dementia, including Alzheimer’s disease. We already know that the prevalence of dementia will grow due to the sheer size of the boomer cohort. In addition, however, it now appears that a recent steady decline in the incidence of cognitive impairment and dementia have ended and are starting to reverse. Dementia is by far the most care-intensive of conditions. More years with dementia (and other disabling conditions fed by the effects of obesity, including mobility disorders) will mean more need for 24/7 care in the face of declining numbers of family caregivers.
Hence the perfect storm. Hence the “2030 crisis.” 2030 is when boomers start becoming the “oldest old” in large numbers.
The boomer generation is defined by a dramatic rise in home ownership. This trend, coupled with real and perceived problems in nursing homes, means that home care has become, by far, the preferred approach to long-term care. With declining numbers of family caregivers, an army of personal care aides, well-trained and better-paid, will be needed to address the coming crisis. Medicare or another universal plan will need to cover the cost.
PNHP and the single-payer bills circulating in Congress fail to place enough emphasis on long-term care and severely underestimate the costs associated with an aging population and declining numbers of caregivers. There is no way to separate long-term care and health care. Living at home alone with dementia, frailty syndrome, or a mobility disorder are an invitation to falls and other safety-related events, a major source of healthcare costs for older adults. Shortages of physicians, nurses, psychiatrists, and social workers with specialties in geriatrics and mental health will create serious concerns for elderly patients both in and out of nursing homes. Medication management will be severely compromised. The health of stressed family caregivers will also suffer.
Over the course of its history, Medicare has added mental health services, prescription drug benefits, and hospice care. Long-term care is the next frontier and boomers and their future caregivers represent a massive potential constituency. It must become a prominent part of the single-payer campaign.
(Henry Moss is a retired baby boomer doing independent academic and public policy research and writing. He has a PhD in philosophy and has written on cognitive science and the history and philosophy of technological progress. His public policy interests include health care, housing and urban development, technological progress, and theories of social democracy.)
The 2030 Caregiving Crisis: A Heavy Burden for Boomer Children, by Henry Moss (250 pages)
For paperback, eBook or free PDF download:
Most single payer advocates certainly support inclusion of coverage for long-term care in a national health program. Inevitably there is concern about the magnitude of the problem, including defining the conditions requiring long-term care, and the costs that care will entail.
In his book, “The 2030 Caregiving Crisis,” Henry Moss discusses the pending crisis when a disproportionately large number of baby boomers will require long-term care at a time when there will be a disproportionate decline in available family caregivers. Addressing this problem now will provide a policy platform which will ease the problems of long-term care once the surge in baby boomers diminishes through attrition.
His book is well researched and well referenced, plus he provides his own constructive thoughts as to addressing this problem. Hopefully it will be a helpful resource as PNHP members clarify and organize our concepts on the financing of long-term care, as a part of our mission to achieve health care justice for all.
Insurers Say Costs Are Climbing as More Enroll Past Health Act Deadline
By Robert Pear
The New York Times, January 9, 2016
Eager to maximize coverage under the Affordable Care Act, the Obama administration has allowed large numbers of people to sign up for insurance after the deadlines in the last two years, destabilizing insurance markets and driving up premiums, health insurance companies say.
The administration has created more than 30 “special enrollment” categories and sent emails to millions of Americans last year urging them to see if they might be able to sign up after the annual open enrollment deadline. But, insurers and state officials said, the federal government did little to verify whether late arrivals were eligible.
That has allowed people to wait until they become ill or need medical services to sign up, driving up costs broadly, insurers have told federal health officials.
“Individuals enrolled through special enrollment periods are utilizing up to 55 percent more services than their open enrollment counterparts” who sign up in the regular period, the Blue Cross and Blue Shield Association, whose local member companies operate in every state, told the administration.
“Many individuals have no incentive to enroll in coverage during open enrollment, but can wait until they are sick or need services before enrolling and drop coverage immediately after receiving services, making the annual open enrollment period meaningless,” Steven B. Kelmar, an executive vice president of Aetna, said in a letter to Sylvia Mathews Burwell, the secretary of health and human services.
A quarter of the applications that Aetna received in the health law’s public insurance marketplace last year came through special enrollment periods, he said.
Kevin J. Counihan, the chief executive of the federal insurance marketplace, said nearly 950,000 people used special enrollment periods to get coverage through HealthCare.gov from late February to the end of June 2015.
“On average,” Aetna said, “special enrollment period enrollees stay with us for less than four months, while enrollees who come to us during the annual open enrollment period maintain their coverage on average for eight to nine months.”
Daniel J. Schumacher, the chief financial officer of UnitedHealthcare, the insurance unit of UnitedHealth Group, said more than 20 percent of its marketplace customers signed up after open enrollment ended last year. And they used 20 percent more health care than people who signed up before the deadline, he said.
Such concerns could portend higher insurance rates broadly. In setting current premiums, insurers say, they did not realize how many people would sign up after the deadline and how much care they would use. That information may affect future rates and benefits.
The federal government allows people to sign up or switch health plans outside open enrollment for various reasons. Lawyers said it was not easy to find a complete list of the eligibility criteria, which have been set forth in regulations, bulletins, official policy statements, manuals and informal “guidance documents.” Some of the reasons are straightforward, like getting married or having a baby.
Others are more complicated and less clear-cut. Consumers may, for example, be eligible for a special enrollment period in “exceptional circumstances” and in “other situations determined appropriate” by the Centers for Medicare and Medicaid Services. The circumstances may include “a serious medical condition” that kept a person from enrolling.
“Most consumers are confused by the rules on special enrollment periods and do not understand the system well enough to try to game it,” said Christine Speidel, a lawyer at Vermont Legal Aid. On the other hand, she said, “many people feel that insurance is not affordable, even with subsidies, and they will call the marketplace to see if they qualify for insurance when they get sick.”
Open enrollment periods for the ACA exchange health plans are limited in duration to prevent people from buying insurance only when a need arises, and then canceling the insurance after the need is met. This “adverse selection” would reduce premium revenues for the insurers while increasing expenditures for medical benefits. This drives up the cost of premiums for everyone else which can cause the healthy to bail out, driving premiums up even more and resulting in the “death spiral,” which is very disruptive to insurance markets.
Circumstances for individuals do change when enrollment is closed, thus the law allows special enrollment so that individuals don’t have to wait up to a year to gain coverage. The problem with special enrollment during closed enrollment periods is that it is the individuals with changing circumstances who also have pressing medical needs that will be compelled to enroll. Thus the payouts by the insurers will increase during these closed enrollment periods. Also, many healthy individuals who feel that they cannot afford their premiums will drop their coverage, decreasing revenue for the insurers. Increased expenditures and reduced revenues is not exactly the business model that insurers seek.
This creates a dilemma for the actuaries. To ensure solvency, premiums will have to be set higher than would be warranted based strictly on the better health of those enrolling during the open enrollment period. Higher premiums then threaten the insurers’ ability to gain market share. This is a problem for even the nation’s largest insurers, as we now see UnitedHealth is withdrawing from the exchanges for this very reason.
The Affordable Care Act perpetuates a market of private plans theoretically designed to use competition to improve quality while reducing costs. But because insurers are not allowed to exercise pure market forces since they must sell their products to people who will actually need to use them, the regulated market of private plans fails under these countervailing forces. Waste escalates because of the greater administrative burden of this defective market, and because of the need of the insurers to distort the functioning of their plans (e.g., higher deductibles and narrower networks) in an attempt to protect their bottom lines.
We can’t keep pretending that we will figure out a way to make private insurance markets work for everyone. We already have over half a century of failure. That’s enough. It’s time to enact a publicly-administered and publicly-financed single payer national health program – an improved Medicare for all.
Health Plan Watchdog Still Seeks Progress After 25 Years
By Phil Galewitz
Kaiser Health News, January 8, 2016
The nation’s oldest private arbiter of what defines high-quality health plans turned 25 last year. The National Committee for Quality Assurance (NCQA) started soon after HMOs became popular in the 1980s, measuring the effectiveness of the first managed care plans as millions of consumers flocked to join them.
Today, NCQA accredits health plans in every state, covering 109 million Americans or about 70 percent of all Americans enrolled in private coverage.
Founding and current president Margaret “Peggy” O’Kane discussed her organization’s past and future recently with KHN’s Phil Galewitz.
Phil Galewitz: What do you see as NCQA’s biggest achievement after 25 years?
Margaret O’Kane: Just getting the measurements out there in a systematic way. We are now finally at a stage where the delivery system is getting it and trying to reorganize itself with primary care medical homes and accountable care organizations.
Galewitz: Is the United States doing a better job for consumers in measuring health plans’ quality of care?
O’Kane: Maybe the glass is half full on measurement, or less than that. I think our strategy was to always walk behind the evidence. We have good measures where there is good evidence on preventive services and chronic diseases like hypertension and diabetes. What we are missing is often in areas where the science is unclear. These also tend to be high-stakes areas of care, like cancer or other complex illnesses.
Galewitz: Are health plans receptive to being evaluated by NCQA?
O’Kane: It’s less than voluntary, I would say. It’s in the health law for exchange plans (to be accredited by NCQA or another accrediting group) and has been driven by employers traditionally. Some plans really question whether it matters what (their) quality is. You see narrow networks emerging and if they are chosen just based on price, that isn’t going to go well among consumers.
Galewitz: How much has NCQA’s work improved the quality of health care that Americans receive?
O’Kane: In the areas we have measured, you can point to real improvements. My main gripe now is what I see as contradictory strategies of high deductibles versus a delivery system reform promoting primary care. If you have to spend out of your own pocket $2,000 or $5,000 before you get to see your primary care physician (for free), many Americans don’t have that money. We are reforming the delivery system and then people can’t afford to see their primary care doctor. That makes no sense.
As our health care system is being refined to supposedly replace quantity with quality in the delivery of health care services, we should learn from the experience of the National Committee for Quality Assurance (NCQA) – one of the more credible and experienced organizations attempting to improve quality in health care. Their founder and president, Margaret “Peggy” O’Kane, has a few lessons for us.
How are we doing on quality measurements? The glass is “half full… or less.” We are not doing well on “high-stakes areas of care, like cancer or other complex illnesses.” How can you ignore the quantity of care that is required for these complex cases and pretend that you are going to make payments based instead on quality that you can’t measure?
And the reception by the exchange health plans of the ACA requirement that they be accredited for quality? O’Kane says that the involvement of the plans is “less than voluntary.” She says, “Some plans really question whether it matters what (their) quality is.” Wow! Plans are setting up narrow networks that are based on price (while ignoring quality – DMc).
Her most important message: “My main gripe now is what I see as contradictory strategies of high deductibles versus a delivery system reform promoting primary care. If you have to spend out of your own pocket $2,000 or $5,000 before you get to see your primary care physician (for free), many Americans don’t have that money. We are reforming the delivery system and then people can’t afford to see their primary care doctor. That makes no sense.”
As the policy and political communities divert their efforts to structural reforms that have not been demonstrated to have more than a negligible impact on quality, the private insurance industry has moved forward with changes that are making health care unaffordable and inaccessible for far too many Americans. When what we need is a strong primary care infrastructure, our health care leaders are allowing the insurers to erect intolerable financial barriers to care. As O’Kane says, “That makes no sense.”
It’s great that we have dedicated organizations such as NCQA and AHRQ to help ferret out and correct quality problems. But we cannot let that distract us from what we really need to do: enact a well designed single payer national health program that will bring us the structural reforms that we desperately need, so all of us can have affordable, accessible, high quality health care.
Medicare Payment Advisory Commission (MedPAC) public meeting, November 5, 2015
Excerpts from the transcript
MR. GRADISON: I think it’s really important not to get too carried away about the benefits of this proposal [paying primary care doctors a fee per patient]. … I’m not sure it’s the answer to a beneficiary’s prayer. Let me call attention to our own document on page 9. Basically, it says … [the] Commission was also concerned about the lack of evidence showing that practice requirements improved outcomes, such as higher quality or lower health care spending. Now, if that’s true, then … why are we doing this? [p. 210]
DR. ALICE COOMBS: So my question is – and then I’m going to be honest with you. I’m going to be real, okay? If I was an internist and I saw this coming at me like this and all the questions that I have, I would say, “That sounds like a good plan for someone.”
[Laughter.] [p. 212]
[MEDPAC CHAIR] DR. FRANCIS CROSSON: Well, I mean, I’ll answer it, to the extent that – I mean, again, we’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction. [p. 214]
DR. [JON] CHRISTIANSON: I just wanted to say that I agreed with everything that Bill [Gradison] said. I think we don’t want to oversell this. If we really think the problem is better care management, we should figure out a way to pay for better care management. This is kind of a trickle-down theory of better care management. [p. 217]
The Medicare Payment Advisory Commission (MedPAC) has become so confused about the “patient-centered medical home” (PCMH) it will soon meet itself coming around the corner.
Since its March 2014 meeting, it has criticized the PCMH for having too many expensive “bells and whistles” that were never “validated” by evidence. But at that same meeting, and at meetings held since, it has discussed recommending the PCMH to Congress under a new name – a “per-beneficiary payment” for primary care doctors who treat fee-for-service Medicare patients. But this “new” payment would be no different in kind from the “care management fees” paid to PCMHs – it would be paid per “attributed” patient per month. And the commission is seriously considering tying the payment to some or all of the PCMH requirements, such as:
* hiring nurses to function as “care managers,”
* 24/7 office hours,
* electronic medical records, and
* “quality” reporting requirements.
In short, by swapping labels, MedPAC commissioners have deluded themselves into thinking they have set aside the PCMH and are now cooking up something new. This delusion caused Dr. Crosson, MedPAC’s new chair, to make the confused statement quoted above: “Well, I mean … I mean, again, we’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction.”
Meanwhile, the commission continues to avoid the most obvious question: If MedPAC’s goal in endorsing the PCMH in 2008 was to raise the incomes of primary care doctors vis-à-vis specialists, why not simply propose raising Medicare’s rates for primary care services? If the commission’s goal was to pour more money into specific “care management” activities, why not name the activities and recommend that CMS pay for them?
But with the exception of the commission’s new vice-chairman, Jon Christianson, the commissioners have refused to raise these questions. During the commission’s discussion of the “per-beneficiary payment” notion at its November 2015 meeting, Christianson stated, “If we really think the problem is better care management, we should figure out a way to pay for better care management.” His comment triggered no further discussion.
If it seems hard to believe 17 smart commissioners could wrap themselves in such intellectual knots, please follow me as I recap first how critical they have become of the PCMH, and then how enthusiastic they have become about the PCMH with the new label – “per-beneficiary payment” – tied to requirements that walk like and quack like PCMH requirements.
At its March 2014 meeting, MedPAC commissioners heaped one criticism after another on the PCMH fad. Then-chairman Glenn Hackbarth began the criticism by calling the PCMH requirements “gold-plated.” He said “electronic medical records and … 24-hour coverage and a long list of other requirements” imposed on PCMHs were not supported by evidence and were too expensive. At least eight other commissioners added their own criticisms, for example, that requiring doctors to give their patients e-mail access merely overloads doctors and does little to improve quality. (For a description of those criticisms, see a comment I posted here.)
One month later, at its April 2014 meeting, one of MedPAC’s staff testified that the evidence on PCMH’s is “mixed” and another stated that the Veterans Health Administration’s “medical home” experiment has failed to improve quality (see pp. 74-75 of the transcript of that meeting).
I give MedPAC credit for doing what many other PCMH proponents refuse to do, which is to acknowledge that the PCMH has mixed effects on quality and no effect, or possibly a negative effect, on cost. But how could MedPAC take that position on the PCMH, then turn right around and propose the PCMH under a new label? I can find no rational explanation for their behavior. The best I can do is tell you what happened.
MedPAC’s discussion of the “per-beneficiary payment” began in earnest at the same March 6, 2014, meeting at which commissioners criticized the PCMH fad. At that meeting, Hackbarth asked the commissioners to discuss the expiration of a temporary 10 percent boost in Medicare payments to primary care doctors ordered by the Affordable Care Act.
Julie Somers of MedPAC’s staff introduced the topic this way:
So now we come to today’s agenda. … [W]e’d like to provide some information about the experience with the primary care bonus program established by PPACA. The program expires at the end of 2015, so we’d also like to hear the commission’s views about extending the current program or replacing it with a per-beneficiary payment for primary care. If the commission is interested in a per-beneficiary payment, then there are design and funding issues that must be explored. [p. 240]
Continuing the bonus program in its current form, and not diving into the complex “design and funding issues” raised by the “per-beneficiary payment” idea, would have been the simplest thing to do. Somers called attention to the simplicity of this approach:
To continue to support primary care after the bonus expires, the primary care bonus program could be extended. It is administratively simple. Practitioners do not apply for the bonus. It is made automatically based on the provider’s specialty and claims history, and practitioners and administrators already have experience with it. [p. 241]
But, no, the commission couldn’t just call for the extension of such a simple mechanism. They agreed they had to take up the “per-beneficiary payment” idea and the convoluted “design and funding issues,” as Somers called them.
And what were those issues? Exactly the same issues raised by the PCMH – issues, incidentally, the commission should have discussed prior to endorsing the PCMH in 2008. Here is how Somers described the “design issues”: “Design issues include how much to pay, how to attribute a beneficiary to a practitioner, and should there be any practice requirements to be eligible for the payment.” (pp. 242-243)
And what “practice requirements” might those be? Somers had PCMH practice requirements in mind, but she didn’t say so. Instead, she said:
For example … practices could be required to improve access by, for example, increasing office hours or maintaining 24-hour phone coverage. A team based approach to primary care could also be encouraged by requiring a care manager to be on staff or processes that facilitate care coordination to be in place. [p. 245]
If you’ve been following the “medical home” fad, you know that “attributing” patients to “homes” is how patients wind up in “homes.” And you also know that “24-hour phone coverage” and hiring “care managers” are among the defining features of PCMHs.
Only one commissioner, Georgia Miller, noticed Somer’s pretense that she was not discussing PCMHs. He raised his hand and asked,
Could you just help me with the patient-centered medical home model, what the requirements are? [H]ow does it relate to this issue, or is that a separate issue, the PCMH model? [pp. 264-265]
Hackbarth replied, apparently without embarrassment, that the PCMH criteria were in fact the “practice requirements” Somers was talking about. He said the commission could decide which of them they wanted to attach to the per-beneficiary payment. “NCQA has various levels of medical home-ness,” he explained, “and the more … characteristics you have, the higher payment you qualify for in some of these [medical home] demonstration projects.” (p. 265)
Hackbarth went on to say that if the commission decided to replace the 10 percent primary care bonus with a per-beneficiary payment (aka the PCMH “care management fee”), it would have to set “some standards on who qualifies for this additional payment.” “And the only thing I’m suggesting,” Hackbarth continued, “is that you can make those standards really rich, you know, require electronic medical records and … 24-hour coverage, and a long list of requirements, or you can make them leaner.” (pp. 265-266)
But which of the “long list of PCMH requirements” did Hackbarth think the commission could do without? He offered no clue, and no member of the commission bothered to ask. By the time Hackbarth resigned in April 2015, he had shed no more light on which of the “long list” of requirements he could do without.
Hackbarth’s comment on “practice requirements” at the March 2014 meeting was the last time anyone on the commission acknowledged that what it is really is talking about is determining which of the features of PCMHs are worth retaining and which should be thrown out. Judging from the new chairman’s “explanation” of what they’re doing now – “[W]e’re sort of starting out. We’re not really starting out, but we’re starting out in a new direction” – no one has any memory of Hackbarth’s answer to Commissioner Miller’s question.
At this date, then, it seems possible that MedPAC will adopt two contradictory positions. It will continue to treat the PCMH with skepticism pending further research, but it will attach “practice requirements” to their proposed “care management fee,” er, rather, per-beneficiary payment, that are identical to requirements PCMHs must meet. In other words, they will propose the PCMH dressed up as something new. If you’re experiencing déjà vu, that’s because the same thing happened to the HMO. It was dressed up as the ACO and presented as something new.
The commission plans to continue discussion of the per-beneficiary payment notion and what requirements should be attached to the payments, possibly at its March 2016 meeting (see p. 231 of the November 5, 2015, transcript here). Will the commission finally get around to a discussion of whether evidence supports any of the PCMH bells and whistles? And if they decide few or none of the bells and whistles are supported by evidence, will they at long last ask, as Commissioner Gradison did, “Why are we doing this?”
Kip Sullivan, J.D., is a member of the board of Minnesota Physicians for a National Health Program. His articles have appeared in The New York Times, The Nation, The New England Journal of Medicine, Health Affairs, the Journal of Health Politics, Policy and Law, and the Los Angeles Times.
Up With Extremism
By Thomas L. Friedman
The New York Times, January 6, 2016
It’s time for a true nonpartisan extremist, one whose platform combines the following:
* A single-payer universal health care system. If it can work for Canada, Australia and Sweden and provide generally better health outcomes at lower prices, it can work for us, and get U.S. companies out of the health care business.
In his opinion piece, Thomas Friedman calls for electing a nonpartisan extremist for president. The first in his recommended list of extremist policy positions is a single payer universal health care system. Great!
The significance of this is that the debate over health care reform is not limited to tweaking the irreparable deficiencies of the Affordable Care Act (Democrats) versus paring back the government role in health care by shifting more of the financial responsibility to patients (Republicans). Although single payer was rejected during the campaign that led to the election of President Obama, it is now clear that Obamacare has perpetuated a wasteful, inefficient system that is increasing financial burdens and further impairing access for patients, even if greater numbers are nominally insured. And the tentative Republican proposals would make affordability and access even worse.
There is now a much broader understanding that single payer would provide the infrastructure that would ensure affordable care for everyone. The spark which has injected this into the presidential campaign is the strong endorsement by Bernie Sanders along with a token acknowledgement by the poll-leading Republican candidate – Donald Trump. We are seeing more single payer endorsements along with limited press coverage confirming that single payer is in play in this election. We should continue our efforts to amplify that. Low odds admittedly, but it’s there.
Just a note on Friedman’s article. He calls for “a nonpartisan extremist for president who’s ready to go far left and far right — simultaneously.” His list of policy recommendations includes some that are simply not acceptable in an enlightened society (mind you, I’m a pacifist). So we should make it clear that, though we are quite pleased with Friedman’s endorsement of single payer, we cannot reciprocate with an endorsement of several of his other policy positions.
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