‘Value Transformation’ and health care reform

Posted by on Tuesday, Mar 25, 2014

By Samuel Metz, M.D.

In their recent paper in the Harvard Business Review, Messrs. Porter and Lee make an eloquent argument that their Value Transformation process will reduce health care costs and improve medical outcomes. They could be right. However, this strategy will certainly fail in the U.S. because it addresses delivery of health care, not financing of health care.

This distinction is crucial. Porter and Lee describe an ideal delivery system, addressing how providers are paid for patient care. Their proposal leaves untouched our financing system, which determines which patients participate, who pays, and how we collect.

If we look at successful health care systems, we find that none finance care with our American private insurance business model.

Delivery of health care in the U.S. is not much different from those in successful systems. What separates the U.S. from successful health care systems (i.e., those providing better to more people for less money than we do) is that millions of Americans lack access to any care at all—at least not until the acuity of their deteriorating health drives them to emergency rooms.

Successful health care systems within our country (there are too few) utilize a variety of delivery systems, and many utilize aspects of the authors’ Value Transformation process. However, all have three common financing characteristics not seen in our American financing model: (1) universal access to comprehensive care without discrimination against the sick, poor, or unemployed; (2) encouragement of patients to seek health care without financial penalty; and (3) financing by publicly accountable, transparent, not-for-profit agencies.

A health care system containing all three characteristics but using only one publicly accountable, transparent, not for profit financing agency is called “single payer.” Many single payer systems apply Value Transformation processes in their delivery systems, and with good results.

In contrast, providers practicing in a health care system lacking these three financing characteristics are motivated primarily to avoid sick patients. We see this as private health insurance companies focus on selling policies to the working wealthy only, to the exclusion of the unemployed poor. Mark Bertolini, CEO of Aetna insurance, neatly summarized this strategy: “margins over market.” An insurance executive’s successful health care system starts by including only those patients sufficiently wealthy to afford policies and sufficiently healthy not to need care.

The Value Transformation process can potentially reduce costs and improve outcomes only for patients who gain access to care. Patients without access will continue to embarrass our public health record and inflate our costs by their desperate attempts to get care through emergency rooms; all this despite the Value Transformation process to which they have no access.

There are three rules to create a successful health care system:

1. If you want to provide comprehensive care to more people for less money, reform the financing system.
2. If you want to dramatically reduce costs without compromising quality, reform the delivery system.
3. If you want Rule #2 to work, you must first apply Rule #1.

The critical shortcoming of Porter and Lee’s Value Transformation process is that it reforms our dysfunctional delivery system without first reforming our dysfunctional financing system. There are no examples of any delivery system succeeding in the absence of a functional financing system.

The complete power of Porter and Lee’s Value Transformation process can be enjoyed when (and only when) a reformed financing system allows all Americans to enjoy access to comprehensive care.

Recommended Reading:
1. Michael E. Porter and Thomas H. Lee. “The strategy that will fix health care” Harvard Business Review, October 2013. http://hbr.org/2013/10/the-strategy-that-will-fix-health-care/ar/1
2. Kenneth Arrow et al. Toward a 21st-Century Health Care System: Recommendations for Health Care Reform. Ann Intern Med 2009; 150:493-495. http://www.annals.org/content/150/7/493.full.pdf+html
3. WC Hsiao et al. What Other States Can Learn From Vermont’s Bold Experiment: Embracing A Single-Payer Health Care Financing System. Health Affairs 2011; 30:1232-1241. http://content.healthaffairs.org/content/30/7/1232.full?sid=56ce15de-c1b1-4dcf-8ffb-a7b3a09871b6
4. Stephen Kemble. Why Competition Among Health Plans Can’t Help Us. OpEd News, November 17, 2011. http://www.opednews.com/articles/Why-Competition-Among-Heal-by-Stephen-Kemble-111117-858.html
5. Jim Kronenberg. A Conversation with David Lawrence. History of Medicine Project, Medicine in Oregon, Summer 2011, page 20. http://associationpublications.com/flipbooks/oma/summer-11/pubData/source/OMA_Summer2011.pdf
6. T.R. Reid. The Healing of America, Penguin Press, New York, 2009. Chapters 10, 13.
7. Mark Stabile et al. Health Care Cost Containment Strategies Used In Four Other High-Income Countries Hold Lessons For The United States. Health Affairs 2013(4); 32:643-652. http://content.healthaffairs.org/content/32/4/643.full.pdf+html

Dr. Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, both advocates for single-payer health care, and of Health Care for All Oregon, an umbrella organization advocating for publicly funded universal care for all Oregonians.

http://blog.hc-disconnects.com/2014/03/24/value-transformation-and-health-care-reform.aspx

PNHP note: This article originally appeared at the blog of Health Care Disconnects, an online journal devoted to sharing evidence-based information about problems and solutions to the dysfunctional health care system in the United States.

Are we forgetting about the underinsured?

Posted by on Tuesday, Mar 25, 2014

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.

America’s Underinsured

By Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and David C. Radley
The Commonwealth Fund, March 2014

The twin goals of health insurance are to enable affordable access to health care and to alleviate financial burdens when injured or sick. It is well known that the uninsured are at high risk of forgoing needed care and of struggling to pay medical bills when they cannot postpone care. Studies further find that insured people who are poorly protected based on their households’ out-of-pocket costs for medical care are also at risk of not being able to afford to be sick.

Using newly available data from census surveys, this report provides national and state-level estimates of the number of people and share of the population that were insured but living in households that spent a high share of annual income on medical care in 2011–12. In the analysis, we refer to these people as “underinsured.” However, this group is only one subset of the underinsured. Our estimates do not include insured people who needed care but went without it because of the out-of-pocket costs they would incur, or the insured who stayed healthy during the year but whose health insurance would have exposed them to high medical costs had they needed and sought care.

The analysis finds that in 2012, there were 31.7 million insured people under age 65 who were underinsured. Together with the 47.3 million who were uninsured, this means at least 79 million people were at risk for not being able to afford needed care before the major reforms of the Affordable Care Act took hold.

In all states, people with low incomes are at greatest risk for being underinsured or uninsured. Nationally, in 2012, nearly two-thirds (63%) of those with incomes below the federal poverty level were either underinsured or uninsured. Among those with incomes between 100 percent and 199 percent of poverty, nearly half (47%) were underinsured or uninsured.

A decade or more of people losing health coverage and a steady erosion in the financial protection of insurance has also put middle-income families at risk. In 2012, one of five people (20%) under age 65 with middle incomes (between 200% and 399% of poverty)—an estimated 15.6 million people—were either underinsured or had no health insurance.

Low- and Middle-Income Households Most at Risk

The exposure to high out-of-pocket medical care costs even when people have insurance reflects insurance trends — including higher deductibles and cost-sharing, as well as gaps in benefits or limits on coverage — in both the employer and individual insurance markets. This puts insured families at risk in terms of access to health care and financial well- being. Studies indicate that low- and middle-income insured individuals and families who face high out- of-pocket costs for medical care relative to their incomes are nearly as likely as the uninsured population to go without care because of costs, forgo care when sick, struggle to pay medical bills, or incur medical debt. Both population groups — underinsured and uninsured — are at far higher risk of access or medical bill concerns than those with more protective coverage.

Premiums for Employer-Sponsored Insurance Have Risen More Rapidly Than Incomes, Value of Benefits Declined

Over the past decade, the cost of health insurance has risen far faster than incomes for middle- and low-income working-age families.

At the same time that premiums have risen, the value of benefits has declined. Deductibles more than doubled for plans provided by larger and small employers. This increase — plus other cost-sharing or limits on benefits — has left insured patients paying a higher share of medical bills. With little or no growth in incomes over a decade, insurance and care have become less affordable.

Medicaid and Income-Related Premium Assistance

Using newly available information on out-of-pocket payments for premiums, we estimate that 29 million insured people — 11 percent of the total under-age-65 population and 13 percent of the insured population under age 65 — paid premiums that exceeded the Affordable Care Act premium contribution thresholds for those at their household income level before reforms. In other words, they had high premium out-of-pocket costs compared with incomes, with “high” defined as in excess of Affordable Care Act contribution thresholds.

However, not everyone who pays high premiums relative to income will be eligible for help. The 29 million insured people includes 13.7 million with incomes below 138 percent of poverty who are paying premiums above the Affordable Care Act thresholds for this group. Of these, 8.8 million had private insurance they bought on their own or through employers. Based on their income alone, they would likely be eligible for expanded Medicaid if their state decides to participate in Medicaid expansions.

For those with incomes above Medicaid eligibility, the law restricts eligibility for premium assistance in marketplaces to people buying insurance on their own and to workers who have employer coverage where the employee’s premium costs for self-only coverage exceeds 9.5 percent of income. Among the 29 million insured with high premium costs in 2012, 11.7 million had employer-sponsored coverage and incomes that would be too high to qualify for expanded Medicaid.

Medicaid Expansion Makes a Critical Difference

Many of the states not participating in Medicaid expansion have among the highest rates of uninsured or underinsured people as a share of their total state populations. Without Medicaid expansion, this vulnerable group will remain at high risk for access, health, and financial problems.

Changing the Insurance Map of the Country

Substantial gains, however, will depend on the plans people choose and state efforts to ensure high-value benefit designs and accessible networks. One concern is to what extent people with low or modest incomes will opt for “bronze” level plans. People choosing bronze-level plans will pay 40 percent of medical care costs on average and thus remain at financial risk. Additionally, in choosing a bronze plan, people with low incomes forgo the cost-sharing subsidies that are tied to silver plans that substantially reduce out-of-pocket spending for medical care. As of February 2014, 62 percent of those enrolling in the new marketplaces selected silver plans, 19 percent had selected gold or platinum, and 19 percent had selected bronze.

In addition, it is important to note that the Affordable Care Act’s limits on out-of-pocket costs for covered benefits also apply only to in-network providers. As discussed in a recent report profiling insured people with medical debt, even with the new limits, the insured may encounter high medical care costs if they receive care from out-of-network clinicians.

From the Conclusion

However, the new marketplaces offer plans that include substantial cost-sharing and annual caps on out-of-pocket patient costs that apply to in-network providers only. With these benefit designs, there is the risk that the nation could convert the uninsured into the underinsured and fail to stop the erosion in insurance protections for people with private insurance coverage.

Full report (40 pages – several Exhibits and Tables):
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report…

This Commonwealth Fund report provides an estimate of the numbers of underinsured – people who could experience financial hardships and impaired access in the face of medical need. Although the authors express optimism that the numbers of uninsured will decline as a result of the provisions of the Affordable Care Act (ACA), there is a high probability that there will be a substantial increase in the numbers of people who will be underinsured.

The private insurance design features supported by ACA makes continued underinsurance an inevitability. The insured are vulnerable because of low actuarial value plans with high-deductibles and other cost sharing, narrow and ultra-narrow networks that impair access to in-network providers, inadequacies of the subsidies, and the perpetuation of an expensive, administrative wasteful model of financing care – a model that we all pay for, including the underinsured.

What is not expressed in the Commonwealth data is the number of people who may not have attempted to access care because of concerns of high out-of-pocket costs. Studies have shown that these people do forgo care that they should have.

A sobering thought is the even larger numbers of individuals not represented in this study. These are the people who remained healthy and never had to test the adequacy of their insurance. Tens of millions of people are vulnerable and would become financially insecure if they did develop significant health problems. This includes many individuals with employer-sponsored insurance. They are underinsured and don’t know it.  Excluding these individuals from the underinsured count results in estimates far below the actual numbers.

The design of ACA makes it clear that both the uninsured and underinsured will remain a problem in the foreseeable future, but it will be underinsurance that will likely provoke widespread discontent. Its prevalence may well become the most compelling reason to abandon the perversities brought to us by the private insurance industry. People will be ready to replace our dysfunctional system with a single payer national health program that would eliminate, for everyone, financial barriers to health care.

AHIP’s Ignagni rejects mandate for comprehensive benefits

Posted by on Monday, Mar 24, 2014

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.

Newsmakers:
Karen Ignagni, President and CEO of America’s Health Insurance Plans (AHIP)

C-SPAN, March 21, 2014

Karen Ignagni:  I would say that what we’ve learned – and I want to go back to this whole transition point – the reason that the decision was made to allow people to stay in their plans is because there was concern being expressed about ten categories of coverage – no matter how meritorious each and every one of those benefits may be – for an individual purchasing, or a small business, sometimes from where they started, which, in general, the old market had very high deductibles – that’s what people preferred to buy because they wanted to keep their premiums low. Then if you take ten categories of coverage and you have a giant step up, well that is a bridge too far for some individuals. And that was being telegraphed pretty clearly in the fall, not from us but from people who were buying the product and would have to spend more. So I would create a lower tier so that people could gradually get into the program, so they could be part of the risk pool so we don’t hold the healthier people outside, so the process could be working the way it was designed, so we get the healthy and the sick. And I think doing things gradually, just from human nature perspective, it just makes more sense.

Marry Agnes Carey:  Wouldn’t a lot of healthy people congregate in that lower tier?

Karen Ignagni:  Not necessarily. We’re not seeing that right now in the bronze, silver and gold. I think by that hypothesis you would have expected an extraordinary amount of people to buy bronze and they have chosen more silver, which is not as high deductible. So they wanted to lower their deductibles. They’re willing to pay a little bit more per month. But the point is that people are choosing. What I would do is give people more choices. I just… human nature suggests that people like that. They’re in control if they have more choices.

http://www.c-span.org/video/?318396-1/newsmakers-karen-ignagnino

One of the more important goals of health care reform was to require plans to provide comprehensive benefits. Although, as with other compromises in the Affordable Care Act (ACA), the legislation fell short, at least they did require that ten categories of benefits be covered, even if insurers were allowed considerable flexibility within each of the ten categories. Now AHIP – the insurers’ lobby organization – is attempting to dismantle the benefit requirement.Suppose we said that males could decline obstetrical benefits if they wanted to, or females could decline prostate cancer benefits, or non-drug using monogamists could decline HIV/AIDS benefits, or young invincibles could decline all benefits except physical trauma, or whatever, what would happen to the risk pooling function of insurance? Obviously that would violate one of the the most important functions of prepaid health care – pooling all risks. Fragmenting risks into a multitude of pools moves away from prepaid health care for everyone and toward each person becoming responsible for paying for the care they use. At the extreme is requiring everyone to pay full costs in cash. How far along that polarity do we move – moving from bad to worse?

Creating another tier below the lowest current metal level – bronze – meets the desires of insurers who want to expand their markets by offering really cheap plans that exclude major benefits, but it does so at a cost of breaking up the risk pools such that people with expected higher costs are concentrated in comprehensive plans, driving premiums up to ever less affordable levels.

“Erin,” responding on the KHN Blog, suggested that we call this new lower metal tier “pyrite” or fool’s gold.

Look how the insurance industry has manipulated the goals of health care reform:

* We wanted to include everyone, and 31 million people will be left out.

* We wanted to reduce financial barriers to care, and the insurers reduced the actuarial value of their plans by increasing financial barriers to care in the form of deductibles and other cost sharing.

* We wanted to slow total spending to sustainable levels. If that is successful under ACA, it will be accomplished by preventing access to essential health care through limited networks and excessive cost sharing, not through true efficiencies such as are found in single payer systems.

* We wanted to improve quality and instead the insurers sell us more worthless administrative services to play ACO and P4P games.

* We wanted to reduce administrative waste, and instead we add greater administrative complexity through the establishment of insurance exchanges and accountable care organizations.

* We wanted everyone to have comprehensive benefits, and now the insurers bring up the old saw about “giving people more choices” because that puts people “in control” and people “like that.” So let’s strip out their benefits so they can choose cheaper plans that relieve insurers of the pesky need of covering expensive disorders.

Single payer would have achieved these goals, but the insurers keep chiseling away at them to meet their own business needs while sacrificing health care for the people. We can’t seem to fix the insurers, so let’s get rid of them.

(Karen Ignagni said that people are willing to pay more for the silver plans in order to lower their deductibles, but that is not the reason. Since Congress knew that people would select plans with the lowest premiums and thus have grossly inadequate coverage – bronze plans with 60% actuarial value – they prohibited those selecting bronze plans from receiving cost-sharing subsidies for out-of-pocket expenses, forcing them to buy up at least to the still inadequate silver plans with 70% actuarial value. Karen Ignagni knows this, so she was being dishonest by covering it up with the people-liking-choice spin, when all choices are bad – except single payer of course.)

by John Geyman, M.D.
http://blog.hc-disconnects.com/2014/03/10/catholic-hospital-systems-a-growing-threat-to-access-to-reproductive-services.aspx

Expansion of Catholic hospital systems is accelerating around the country, partly by acquiring non-Catholic hospitals. This trend is posing an increasing threat to access to care in two major areas—reproductive services and end-of-life care. Ethical and Religious Directives for Catholic Health Care Services (the ERDs) are being enforced by the bishops more vigorously in many parts of the country, holding their employed physicians to strict adherence to the ERDs or loss of employment. Meanwhile patients in many locations, especially rural areas, are finding it increasingly difficult to gain access to essential care.

Ten of the 25 largest health systems in the U.S. are Catholic-sponsored, where health professionals are prohibited from providing health services or honoring patients’ health care requests in these areas. Washington State has the highest proportion of acute care hospital beds—45 percent—of any state in the country. In many instances, health professionals employed by Catholic hospitals cannot provide counseling or referrals based on religious grounds. Nuns have for years been more permissive in these areas, but increasingly the bishops are dictating what services can be provided.

These are some of the ERDs restricting common needs of women in their childbearing years: (2)

  • “Catholic hospitals may not promote or condone contraceptive practices.” (Directive 52)
  • “Abortion (that is, the directly intended termination of pregnancy before viability or the directly intended destruction of a viable fetus) is never permitted.” (Directive 45)
  • “In case of extrauterine pregnancy, no intervention is morally licit which constitutes a direct abortion.” (Directive 48)
  • “Direct sterilization of either men or women, whether permanent or temporary, is not permitted in a Catholic health care institution.” (Directive 53)
  • “The free and informed health care decision of the person. . . is to be followed so long as it does not contradict Catholic principles.” (Directives 28 and 27).
  • “Catholic health care services must . . . require adherence to [the Directives] within the institution as a condition for medical privileges and employment.” (Directive 5)
  • Other ERDs prohibit abortion even in cases of rape or incest (Directive 45), and in-vitro fertilization (Directives 37, 38, 39) (3)

 

It appears that there is some variation from one institution to another how these Directives are interpreted under specific circumstances. Often there are gray areas when health care professionals are unsure how the ERDs will be interpreted. But the proscription against abortion is inviolate in all Catholic institutions.

The following cases in two parts of the country indicate how extreme and harmful strict adherence to the ERDs can be:

Sierra Vista is a rural community about 80 miles southeast of Tucson, AZ with one hospital serving a three-county area. The local hospital had been secular until purchased in 2010 by the Carondelet Health Network, a member of Catholic-sponsored hospitals. ERDs were to be followed at the time of transfer of ownership. Shortly thereafter, a woman presented to the Emergency Room 15-weeks pregnant with twins after miscarrying one of the twins at home. The remaining twin had a heart beat. The attending physician concluded that any attempt to continue the pregnancy would pose high risks of loss of the child as well as  hemorrhaging and infection for the mother. As he and the staff were preparing to complete the miscarriage, a hospital administrator intervened and ordered the patient transferred to another hospital 80 miles away, where she did receive necessary care. The medical staff felt misled since they had previously been assured that they could provide appropriate care for miscarriages. (4)

  • A woman 18 weeks along in her pregnancy came to Mercy Health Partners, a Catholic-sponsored hospital in Muskegon, Michigan, where it is the only hospital with two campuses in the community.  Her water had broken at home and contractions had started.  She was told that she had premature rupture of the membranes (PROM), that nothing could be done, and to go home. She was not informed that there was almost no chance that the fetus could survive and was not counseled about risks of non-treatment to herself. She returned to the hospital the following morning with painful contractions, bleeding and an elevatedtemperature. Her contractions were monitored and she was given Tylenol. She was again sent home after the temperature came down. Later that same night, she returned to the hospital again in severe distress. While the staff was preparing to send her home, she delivered a very premature son, who died within hours. She soon developed infection that had developed after her membranes ruptured. The American Civil Liberties Union (ACLU) has filed a lawsuit contending that “a young woman in a crisis situation was put at risk because religious directives were allowed to interfere with medical care. . . Patients should not be forced to suffer because of a hospital’s religious conviction.” (5)

A 2012 national study by clinician researchers at the University of Chicago found that 53 percent of obstetrician-gynecologists practicing in Catholic-sponsored hospitals had conflicts over religious-based policies. (6)

The above cases and ERDs raise a number of important questions about the influence of religious directives in medical care. One relates to the Emergency Medical Treatment and Active Labor Act (EMTALA) enacted in 1986. It requires any hospital that operates an Emergency Room and receives Medicare funds to stabilize a patient determined to have an emergency situation, including active labor, regardless of ability to pay. Centers for Medicare and Medicaid Services (CMS) requirements further state that “If a hospital is unable to stabilize a patient within its capacity, or if the patient requests, an appropriate transfer should be implemented.” (7)

Other issues are involved in this controversy over ERDs interference with generally accepted, evidence-based health care. Here are just two:

  • Given the various forms of tax benefits that Catholic hospitals receive as not-for-profits, shouldn’t we expect them to serve the public interest above their private religious interests? Many Catholic hospitals have a long tradition of public service in both patient care and medical education, and have often been located in areas of special need. But that is changing too. Some have drifted away from their traditional safety net responsibilities. Their high costs often create financial barriers to care, and they provide less charity care than one might think. A recent study comparing charity care by different kinds of U.S. hospitals found that Catholic-sponsored hospitals spend just 2.8 percent of their total gross patient revenue on charity care, one-half that spent by public hospitals. (8)
  • Should Catholic-sponsored hospitals receive funding from public hospital districts when they restrict access to maternity services based on the ERDs? A recent ruling by the State Attorney General in Washington State stated that “public hospital districts that offer maternity services must provide equivalent benefits, services or referrals for birth control and abortion as required by Washington State’s Reproductive Privacy Act.” (9) The fallout of that ruling is still unclear.

From the above, we can conclude that the ERDs, zealously interpreted by Catholic Bishops in U.S. Catholic-sponsored hospitals, constitute a threat to the health and well-being of many women seeking reproductive services in these hospitals. More oversight is needed by public agencies to ensure that the public interest is being served. This issue is even more important at this particular time as the Tea Party and the Christian right accelerate their attacks on women’s reproductive rights and freedoms, despite the fact that more than two-thirds of voters support women’s rights to abortion, a constitutional right since the Roe v. Wade Supreme Court’s decision in 1973. Michigan’s mostly male Republican-dominated Legislature, without hearings or substantive debate, recently passed the Abortion Insurance Opt-Out Act, which bans abortion coverage, even in cases of rape or incest, from nearly all health insurance policies issued in the state.  Other states are restricting access to care by closing abortion clinics. Some 24 states have banned some forms of abortion coverage from policies purchased on the health care exchanges. (10) So this issue is even more critical in the heat of political battles in this election cycle. The medical profession and forces in the public interest need to prevail against undue influence of religion in health care.

Visit: https://www.hc-disconnects.com

References:

1.    Uttley, L, Reynertson, S, Kenny, L et al. Miscarriage of Medicine: The Growth of Catholic Hospitals and the Threat to Reproductive Health Care. ACLU and MergerWatch. December 2013.
2.    United States Conference of Catholic Bishops, Ethical and Religious Directives for Catholic Health Care Services (5tg ed, 2009), available at:  http://www.usccb.org/issues-and-action/human-life-and-dignity/health-care/upload/Ethical-Religious-Directives-Catholic-Health-Care-Services-fifth-edition-2009.pdf  [hereinafter Directive(s)].
3.    O’Brien, J. How the Bishops’ Directives derail medical decisions at Catholic hospitals. Catholics for Choice, December 4, 2013.
4.    Cohn, J. Unholy alliance. The New Republic, February 22, 2012.
5.    Hausman, JS. ACLU’s abortion lawsuit claims Catholic policy barred care for Muskegon woman at Mercy Health Partners. All Michigan, December 2, 2013.
6.    Stulberg, DB, Dude, AM, Dahlquist, I et al. Obstetrician-gynecologists, religious institutions, and conflicts regarding patient-care policies. Am J Obstet Gynecol 207 (1): 73, 2012.
7.    Centers for Medicare & Medicaid Services. Emergency Medical Treatment & Labor Act (EMTALA). Available at: cms.gov
8.    Ibid # 1, Table 4.
9.    Connelly, J. State AG: Public Health Districts must offer birth control, abortion. Seattle Post Intelligencer, August 21, 2013.
10.    Reitman, J. The stealth war on abortion. Rolling Stone Politics, January 15, 2014.

Buying platinum and getting bronze

Posted by on Friday, Mar 21, 2014

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.

Obamacare Limits Choices Under Some Plans

By John Tozzi
Bloomberg Businessweek, March 20, 2014

Ben Rosenthal was treated for prostate cancer four years ago and had gallbladder surgery the year before that. A former manager at a market-research firm in Los Angeles, Rosenthal, 57, paid for his own health insurance. Last fall, when his plan was discontinued because it didn’t meet standards set by the Affordable Care Act, Rosenthal bought the best insurance coverage he could find, a top-tier “platinum” policy from Blue Shield of California that costs $792 a month. He figured it would provide access to top hospitals. Then in February he learned the plan wouldn’t cover the hospitals where he was used to being treated.

Rosenthal is one of millions of Americans who have purchased insurance under the Affordable Care Act and are discovering that many of the new plans offer a narrow network of doctors and facilities. “If I had anything happen, I wouldn’t want to go to a hospital that I’m not familiar with and with doctors I don’t know,” he says.

Since the ACA created marketplaces for private health plans last fall, insurers expecting to lure customers with low premiums have fashioned smaller networks of medical providers. By cutting out expensive hospitals and negotiating favorable rates with doctors in exchange for sending more patients their way, insurers can keep premiums down. Blue Shield’s new network includes 43 hospitals in Los Angeles County, about 64 percent of what its standard coverage offers, spokeswoman Lindy Wagner says in an e-mail.

In addition to having fewer options, buyers are making decisions about which plans to buy based on incomplete or misleading information, says Karen Pollitz, senior fellow at the Kaiser Family Foundation, a health policy research group. “Consumers have a very limited ability to shop in advance and evaluate provider networks,” she says.

Plans on healthcare.gov and state marketplaces are required to include links to directories that show which providers accept the insurance. But the information is often missing, wrong, or difficult to navigate, says Oliver Kharraz, chief operating officer of ZocDoc, an online appointment booking company. ZocDoc tried to verify the accuracy of hundreds of directories by calling doctors listed as in-network providers. About half the listings were wrong, Kharraz says. The California exchange, one of 15 state marketplaces that operate independently of healthcare.gov, created a central directory on its website but took it down on Feb. 6 because of errors.

Pressures on insurers to keep premiums low—state regulators can reject plans that are priced too high—may mean patients will have to learn to live with restricted choices. “The industry’s had to find ways to cut costs,” says Hasday of Frenkel Benefits. The result, he says, is “much less transparent for the consumer.”

Reader comment: John Alexander

I had the exact same problem as Mr. Rosenthal only in Florida with Blue Cross Blue Shield. Got screwed, as I also picked the Platinum plan and found out my hospital and doctors were not covered. The best research I did before hand indicated I would be covered and found after the fact I was not. Got furious with BCBS and they agreed to correct a few cost items with my doctors. They are playing dollar games with our health and I am completely frustrated. I am not upset with Obama-Care, only with the sligh and sneaky Insurance companies. Cannot drop my insurance and/or change until November of this year. What a fiasco. A singly payer system would correct all of this smoke and mirror games played by the Insurance industry.

http://www.businessweek.com/articles/2014-03-20/obamacare-limits-choices…

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In Obamacare, go for bronze health plans. For most people, buying up to gold or platinum plans is a waste of money

By Scott Gottlieb
The American Enterprise Institute (AEI), January 24, 2014

We analyzed dozens of Obamacare plans, and found one striking result. The networks of providers, and in many cases the drug formularies, are the same whether you’re buying a particular insurer’s bronze plan, or purchasing the same insurance option in a gold or platinum offering. My American Enterprise Institute colleague Kelly Funderburk and I posted some of our data here.

The bottom line is this. When you’re choosing a particular insurance offering, you typically can’t trade up to a better benefit by buying the gold or platinum variety of that plan. It’s usually the exact same benefit regardless of the metal you choose.

So what varies between these different metal plans? Typically, just the co-pay structure and deductibles. As you pay higher premiums for a gold or platinum plan, your deductibles and co-pays will decline. The insurer will typically cover 60 percent of expected medical expenses in a bronze plan, 80 percent in a gold plan and 90 percent in a platinum plan. So, by buying the costlier plans, all you’re doing is fronting a higher premium to buy down your anticipated out of pocket costs. You’re not getting a better network of doctors or a better formulary of drugs.

http://www.aei.org/article/health/in-obamacare-go-for-bronze-health-plan…

Data to support this claim: http://www.scribd.com/doc/201871033/Comparison-of-Bronze-Versus-Platinum…

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Hospital networks: Configurations on the exchanges and their impact on premiums

McKinsey & Company, December 14, 2013

Narrow and ultra-narrow hospital networks are more prevalent (70 percent of all networks), increasing the variety of network configurations available to consumers

Broader network offerings are fewer than in 2013, yet remain available in almost every rating area we analyzed. The prevalence of narrower networks varies across markets, with the average percent contraction of incumbents’ network breadth between 2013 individual market networks and 2014 individual exchange networks ranging from 11 to 60 percent.

Products with broad hospital networks reveal higher premiums, with a median premium increase of 26 percent between broad and narrower networks of the same carrier, product type (e.g., HMO, PPO), metal tier, and rating area. Also, the majority (84 percent) of lowest-price silver products utilizes narrow or ultra-narrow networks

Across silver tier networks in our 20 analyzed rating areas, 58 percent of the lowest-price products utilize ultra-narrow networks and another 26 percent utilize narrow networks. Network breadth appears to be positively correlated with premium levels in many cases, but the use of narrower networks is common at all price points.

http://www.mckinsey.com/client_service/healthcare_systems_and_services/l…

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Out-of-network coverage in New York? We left it up to the insurers

By Craig Gurian
Remapping Debate, October 30, 2013

New York’s health insurance exchange (called “NY State of Health”) offers individuals and families numerous insurance plan options at various “metal” levels. What it doesn’t offer in most parts of the state are plans that provide coverage for non-emergency out-of-network care. In a sample Manhattan zip code, for example, there are 62 plans available at all metal levels. Not one of those plans pays for out-of-network care.

Why then did New York State not require out-of-network coverage? “We left it up to the insurers,” said (Department of Health’s Randi) Imbriaco, and the insurers, she continued, arguing that “a closed network helps keeps costs low,” chose not to provide out-of-network coverage in most of New York State, including New York City (some plans in the western part of New York State do offer such coverage).

Dr. Andrew D. Coates is an internist based in upstate New York who is president of Physicians for a National Health Program (PNHP), an organization that advocates for a single-payer health insurance system. Coates, who was speaking during the interview for himself and not as a representative of PNHP, agreed with the idea that the lack of out-of-network options would enhance the ability of insurance companies to engage in cost cutting, regardless of whether patients were harmed, as, for example, in a push for doctors to see more and more patients each day.

He thought that doctors were increasingly being put in an “ethical bind” where their medical instincts might tell them in a particular instance to recommend an out-of-network physician — the “one oncologist that you can think of that should really evaluate what to do next” in the case of a rare cancer — even as they knew that following that recommendation would be financially ruinous for the patient.

More broadly, in Coates’ view, the greater empowerment of insurance companies was accelerating a turn towards “a corporate medical model that threatens to squeeze the humanity out of our interaction with our patients.”

http://www.remappingdebate.org/article/out-network-coverage-new-york-we-…

According to the Bloomberg Businessweek report, Ben Rosenthal and reader John Alexander purchased the highest tier plans available – platinum plans – to ensure that they would have coverage for their current physicians and hospitals. No way. Insurers have pushed the perversity of narrow network plans all the way to the top.

Before Barack Obama was even nominated, the Democratic strategists had already decided that “Choice” would be a campaign slogan to market health care reform. Some of us protested that Celinda Lake and Herndon Alliance were pushing “choice of private health plans” when what the Democrats should have been advocating was “choice of physicians and hospitals.” It is clear which faction won this debate, as single payer supporters had the door slammed on them.

But look at the consequences. We were promised that we would have our choice of any plan we wanted with benefits as rich as desired, and with a selection of any health care providers we preferred. We could choose our doctors and our hospitals. But what happened?

So they did set up four levels of plans that we could choose from, plus a fifth catastrophic plan as an option for younger individuals. So we could buy a cheap bronze plan that would cover an average of 60 percent of our health care costs, 70 percent for silver, 80 percent for gold, all the way up to an expensive platinum plan that would cover 90 percent of costs. But there would be only negligible differences in the benefits since all plans had to cover the same ten categories of benefits, though some variation within each category is allowed as long as it had the same actuarial value.

But the shocker is the networks that the insurers established. As the AEI report indicates, for plans offered by the same insurer in the same market, the provider networks were just as limited for the high end platinum plans as they were for the cheapest bronze plans. If you want your medical bills paid, you do not have a choice of physicians and hospitals. You have to stay in network. Typically seventy percent of the providers are outside of the narrow network plans offered through the exchanges.

The Remapping Debate report reveals a further complication. Previously plans were available that provided reduced payments for care obtained out of network, with the patient paying a greater share of the costs. Now in areas such as New York City, none of these plans are available through the exchanges. You must stay in network or pay the full bill.

According to the McKinsey report, in some markets plans are available with broader networks, but these are less prevalent and declining in availability, and they are exorbitantly expensive. They will likely be subject to the death spiral since most markets do not have enough super wealthy individuals to maintain a vibrant market of broad network plans. The super wealthy then will simply pay their own bills.

So the Democrats traded off our choice of physicians and hospitals for a choice of deductibles and copayments, as the insurers took away the choices that we actually wanted. The narrow and ultra-narrow networks were a decision of the insurers, not us. We are getting what they want rather than what we want, simply because the Affordable care Act was designed to leave the insurers in charge.

As we’ve said before, all of this would go away if only we would enact a single payer national health program. As PNHP president Andy Coates says, physicians are placed in an “ethical bind” as they practice under “a corporate medical model that threatens to squeeze the humanity out of our interaction with our patients.”

Got cancer? Don’t buy a plan in our network.

Posted by on Thursday, Mar 20, 2014

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.

Health Law Concerns for Cancer Centers

By Ricardo Alonso-Zaldivar
Associated Press, March 19, 2014

Cancer patients relieved that they can get insurance coverage because of the new health care law may be disappointed to learn that some the nation’s best cancer hospitals are off-limits.

An Associated Press survey found examples coast to coast. Seattle Cancer Care Alliance is excluded by five out of eight insurers in Washington state’s insurance exchange. MD Anderson Cancer Center says it’s in less than half of the plans in the Houston area. Memorial Sloan-Kettering is included by two of nine insurers in New York City and has out-of-network agreements with two more.

In all, only four of 19 nationally recognized comprehensive cancer centers that responded to AP’s survey (members of the National Comprehensive Cancer Network) said patients have access through all the insurance companies in their state exchange.

Not too long ago, insurance companies would have been vying to offer access to renowned cancer centers, said Dan Mendelson, CEO of the market research firm Avalere Health. Now the focus is on costs.

“This is a marked deterioration of access to the premier cancer centers for people who are signing up for these plans,” Mendelson said.

Those patients may not be able get the most advanced treatment, including clinical trials of new medications.

And there’s another problem: It’s not easy for consumers shopping online in the new insurance markets to tell whether top-level institutions are included in a plan. That takes additional digging by the people applying.

To keep premiums low, insurers have designed narrow networks of hospitals and doctors. The government-subsidized private plans on the exchanges typically offer less choice than Medicare or employer plans.

By not including a top cancer center an insurer can cut costs. It may also shield itself from risk, delivering an implicit message to cancer survivors or people with a strong family history of the disease that they should look elsewhere.

For now, the issue seems to be limited to the new insurance exchanges. But it could become a concern for Americans with job-based coverage too if employers turn to narrow networks.

In a statement, Anthem said its network was based on research involving thousands of consumers and businesses. “What we learned was that people are willing to make trade-offs in order to have access to affordable health care,” the company said. “Our provider networks reflect this.”

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_TOP_CANCER_CEN…

Members of the National Comprehensive Cancer Network (http://www.nccn.org/members/network.asp)

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2015 Letter to Issuers in the Federally-facilitated Marketplaces

CMS, March 14, 2014

Section 3. Network Adequacy

Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a provider network must maintain a network that is sufficient in number and types of providers… to assure that all services will be accessible to enrollees without unreasonable delay. All issuers applying for QHP certification will need to attest that they meet this standard as part of the certification/recertification process.

CMS will assess provider networks using a “reasonable access” standard, and will identify networks that fail to provide access without unreasonable delay as required by 45 C.F.R. 156.230(a)(2).

If CMS determines that an issuer’s network is inadequate under the reasonable access review standard, CMS will notify the issuer of the identified problem area(s) and will consider the issuer’s response in assessing whether the issuer has met the regulatory requirement and prior to making the certification or recertification determination.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/20…

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Kaiser Health Tracking Poll: February 2014

By Liz Hamel, Jamie Firth and Mollyann Brodie
KFF.org, February 26, 2014

The latest Kaiser Health Tracking Poll finds that, in general, the public leans towards more expensive plans with broader networks. About half (51 percent) say they would rather have a plan that costs more money but allows them to see a broader range of doctors and hospitals, while just under four in ten (37 percent) prefer a plan that is less expensive but allows them to visit a more limited range of providers. While older individuals and those with higher incomes exhibit a clearer preference for more expensive plans with broader networks, younger adults and those with lower incomes are more evenly divided in their preferences. But those who are either uninsured or currently purchase their own coverage – a group that is most likely to be in a position to take advantage of new coverage options under the ACA – are more likely to prefer less costly narrow network plans over more expensive plans with broader networks (54 percent versus 35 percent). Those who currently get their insurance through an employer (and are more protected from the cost of coverage) have the opposite preference: 55 percent prefer a more expensive plan with a broader network, while 34 percent would rather have a cheaper narrow network plan.

Those who prefer narrow network plans may be less likely to prefer them if it means they can’t see their usual providers. When those who prefer a less costly narrow network plan are presented with the possibility that they would not be able to visit the doctors and hospitals they normally use, the share who continue to prefer this option drops from 37 percent to 23 percent among the public overall, and from 54 percent to 35 percent among the uninsured and those who buy their own insurance.

On the other hand, when those who initially prefer a more expensive plan with a broader network are told that they could save up to 25 percent on their health care costs, the share continuing to prefer the more expensive option drops from 51 percent to 37 percent among the public overall, and from 35 percent to 22 percent among those the uninsured and those with non-group coverage.

http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-fe…

For decades we have been hearing heartrending stories of children and adults under 65 who develop cancer but were uninsured. For those of us striving for a comprehensive health care program for everyone, there could not be a greater motivating force than the desire to eliminate forever the twin tragedies of impaired access to care and personal financial ruin for these unfortunate cancer victims.

The Affordable Care Act brought us expanded access to private insurance plans with incentives for the insurers to provide plan innovations to help slow spending on health care. Although plans already were using limited networks to leverage lower prices from the providers, the degree to which they would further narrow networks was not expected, except perhaps by the cynics amongst us.

But the insurers have no shame. Cancer management is expensive. What better place to restrict access could there be than to remove most members of the National Comprehensive Cancer Network from many of their insurance networks. Only four of nineteen of these centers are included in all exchange plan networks within their respective states.

CMS tells us that they will use a “reasonable access” standard when the plans are recertified for the federal exchanges next year. This is a relative rather than an absolute standard. They have no intention of opening up insurer networks to all comers. That would defeat the insurance innovation of controlling costs by blocking access to out-of-network providers, especially the expensive ones such as the members of the National Comprehensive Cancer Network.

The latest Kaiser tracking poll is of concern since it shows that lower-income and uninsured people will select the plans with more restricted networks simply because the premiums are lower. No centers-of-excellence cancer care for them.

Although insurers are prohibited from denying coverage, just think of the advantage they would have in avoiding adverse selection by being able to tell those patients who have cancer that they really don’t want to buy the plans they offer since the nation’s noted cancer institutions are not covered. They can do the cancer victim a favor by sending her to a competitor. Then they can retreat into their headquarters to devise yet more insurance innovations that work this well.

A single payer national health program would not have networks. Patients could go anywhere. With an improved primary care infrastructure, they would receive assistance in obtaining the best care for their medical condition. For those with cancer, there would be no private insurers profiting off of discount cancer care, though the single payer system would take care to see that the services are priced right for the benefit of us taxpayers who would be financing our health care system.

“Medical home” proponents should focus on specific services for specific patients

Posted by on Wednesday, Mar 19, 2014

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.

Medical Home: An Evolving Model of Primary Care

By Melinda K. Abrams
Commonwealth Fund Blog, February 25, 2014

Today, the Journal of the American Medical Association (JAMA) released a study, cofunded by The Commonwealth Fund, evaluating a three-year medical home pilot in Pennsylvania. The study, led by RAND’s Mark Friedberg and colleagues, found the program was not associated with significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the study’s findings underscore what we already knew about this team-based model of primary care: we need to continue to improve how care is delivered, how providers are paid, and how the model is implemented in different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned more about how best to implement an effective patient-centered medical home. For example, it’s become clear that the payment model needs to reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with complex medical conditions are more likely to see an impact on outcomes and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria used by NCQA and other accrediting organizations need to better reflect meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Pri…

The February 25 edition of JAMA published a study of “patient-centered medical homes” (PCMH) by Mark Friedberg et al. The authors reported that PCMHs had no effect on costs and almost no effect on quality (PCMHs outperformed the control clinics on only one of 11 quality measures). In fact, it appears that PCMHs raised costs when the costs associated with setting up PCMHs and rewarding PCMH doctors is taken into account.

The PCMH may not survive much longer if research continues to show that it cannot cut costs. The loss of the “medical home” metaphor will be inconsequential, but if the termination of the PCMH experiment sets back the campaign to strengthen the primary care sector, that will be a significant loss. To avoid that outcome, PCMH proponents should cease hyping the PCMH as a cost containment device applicable to entire “populations” and instead focus on specific services for specific patients.

Cutting costs has always been one of the primary goals of PCMH advocates. For private insurers, it is not merely a goal – it is a precondition. Unless it is ordered to do otherwise by state legislatures or Congress, the American insurance industry will not, over the long haul, subsidize clinics to provide “home” services if those services do not reduce the industry’s net costs – their subsidies to PCMHs plus their expenditures on claims. Nor will clinics certified as PCMHs provide, over the long term, the services PCMHs are expected to provide if insurers refuse to compensate them for those services. And if insurers and PCMHs refuse to pay for those services, it is extremely unlikely patients can be persuaded to pay for them.

The “medical home” label was originally coined to refer to clinics which held all the records of children with special needs. But in 2007 the concept was greatly expanded by the American Academy of Family Physicians and three other primary care specialty groups and promoted as a means to bring more resources into the entire primary care sector while simultaneously cutting costshttp://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiati…. As Robert Berenson et al. put it in a 2008 paper, “[T]he medical home can be viewed as an alternative way to recognize and support primary care activities, particularly those that are not considered to be part of evaluation and management service codes….”http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner and other PCMH advocates put it in a 2012 paper for the Commonwealth Fund, “Among the experts, stakeholders, and patients consulted for this report, there was broad agreement that … sustaining the PCMH model and making the case for increased primary care payments hinge on success in reducing health care costs.”http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report…

Promoting the “medical home” as a cost-containment tool rather than simply calling for more resources for primary care may turn out to have been a mistake. It is becoming increasingly apparent that the cost-cutting prowess of the “home” was vastly exaggerated by its proponents. It should have been described only as an approach or model that might cut costs if applied to specific categories of chronically ill patients. Thanks to research like the paper by Friedberg et al., that realization seems to be dawning on PCMH advocates.  The comment on the Commonwealth Fund blog quoted above is one example. An editorial accompanying the JAMA paper, aptly entitled “One size does not fit all,” is another. Even the ever-optimistic Patient-Centered Primary Care Collaborative (which last year added Liz Fowler to its board http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-…) said of the JAMA paper, “There was no targeting and/or analysis of chronically ill patients.” http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-m…

The “medical home” movement would be well advised to stop exaggerating the cost-containment powers of the PCMH and instead call for experimentation and research on specific services for specific types of chronically ill patients. Let me offer one example suggested by the Friedberg paper. The PCMH model studied by Friedberg et al. focused on diabetes care – six of the 11 quality measures measured some aspect of diabetes treatment. The one measure at which the PCMH clinics excelled turned out to be a diabetes measure (kidney exams). How did the PCMH clinics achieve this laudable outcome? We don’t know, but it is reasonable to infer that the high percentage of diabetes measures in the quality measurement set caused the clinics to “teach to the test” – to concentrate resources on diabetes patients, possibly at the expense of patients without diabetes. Did they use some or all of the diabetes disease management techniques that have been shown to improve the health of diabetics and pre-diabetics? We don’t know.

If instead of testing the impossibly amorphous, one-size-fits-all “home” concept, the PCMH clinics had tested their ability to improve the health of diabetics with specific treatments and interventions, we might now be reading a paper with useful information about what treatments work for diabetics and whether those treatments cost more to deliver than they saved in future medical costs. Instead we are left to scratch our heads about why the latest over-hyped managed care fad with the saccharine name isn’t working.

The AAFP and other proponents of the “medical home” should never have burdened the concept with the expectation of cost containment. If they were serious about cost containment, they should have endorsed single-payer legislation. If they were serious about strengthening the primary care sector, they should have called for more money for primary care, period.

Stuck out-of-network and vulnerable

Posted by on Tuesday, Mar 18, 2014

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.

Warning: Opting Out Of Your Insurance Plan’s Provider Network Is Risky

By Michelle Andrews
Kaiser Health News, March 18, 2014

Many plans sold on the health insurance marketplaces offer a tradeoff: lower premiums in exchange for limited networks of providers. But consumers who opt for a narrow network plan with the idea that they’ll go out of network when necessary may be taking a big financial risk.

The health law generally places limits on how much consumers can be required to pay out of pocket for medical care (not including premiums). In 2014, the limit for an individual plan is $6,350 and for a family plan, $12,700. But those limits apply only to care provided by doctors and hospitals in a plan’s provider network. There may be a separate out-of-pocket maximum for services provided out of network in marketplace plans, or no cap at all.

Similarly, the health law requires that preventive care such as vaccines, cancer screenings and annual checkups be covered at no cost to consumers in most health plans. If someone uses an out-of-network provider, however, they can be charged.

Going out of network opens the door to higher costs in other ways as well. Plans may require patients to pay a higher copayment or coinsurance for an out-of-network provider. In addition, since the doctors, hospitals and other providers are not under contract with the insurance company, in many states those providers may bill patients for any charges not covered by the insurance, a practice known as “balance billing.” The contracts signed by providers who join plan networks generally contain provisions that prohibit them from balance billing enrollees.

Plans sold on the marketplace are divided into four levels based on the amount of consumer cost sharing required. On average, a bronze plan pays for 60 percent of covered medical services, a silver plan pays for 70 percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But those percentages don’t take any out-of-network care into account.

A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.

The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.

However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.

“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians.

Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.

“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”

http://www.kaiserhealthnews.org/Stories/2014/March/18/Michelle-Andrews-o…

Most people who have been paying any attention at all are quite aware that health plans inside and outside of the exchanges limit coverage to physicians and hospitals within their contracted networks. Although some plans may also offer limited coverage outside of the networks, it is less clear as to the extent and adequacy of that coverage. This article helps to clarify that issue by showing how muddled the coverage is.

Some of the traps include care provided outside of HMOs, care provided after an emergency patient is stabilized, free preventive services that may not be free outside of the network, services provided within network that are not benefits of the specific plan selected, and so forth. What is particularly treacherous is that, not only do you usually have to pay in full for these services, but your payments may not apply to your maximum out-of-pocket expenses, which can be unlimited out-of-network. The ACA promise that out-of-pocket expenses will be capped for the year ($6,350 for an individual and $12,700 for a family) comes from the same book of promises that gave us “you can keep your plan if you like it.” It is possible to end up with expenses over six figures. That is quite a whack for the person who was trying to do the right thing by buying a qualified insurance plan.

The precise out-of-network coverage depends on the specifications of the plan selected, and there are very few standards with which the plans must comply. So how do you select the right plan?

When people purchase their plans, they usually look first at the premium. Then they look at the deductibles and then the copayments or coinsurance. Usually, when assisted by a plan navigator or equivalent, they will also look at the tax credits for the premiums and the subsidies for cost sharing. Since many benefit from these they often select a silver plan because that is the only tier that includes cost-sharing subsidies.

The next step is to check the list of providers to see if your physician(s) or hospital(s) are on the list. This is where it becomes more tricky since those lists are often difficult to access, and they can be quite unreliable. Even physicians can be confused since they may be included on an insurer’s plan outside of the exchanges, but excluded from the exchange plans, and yet they may not be aware of the exclusion.

Finally, just try to find out the precise rules for coverage of care obtained outside of the network. Since there are very few standards, it is important to know this. The various insurers may approach such charges quite differently. You could end up with only modest additional expenses, but it is not too difficult imagining a six-figure bill when you are admitted to an out-of-network hospital. The insurer may cover the charges in the emergency room, but once the stabilized patient is admitted, she may well be on her own for all additional charges.

Think of how administratively complex the private insurers have already made our system. Then think of the administrative excesses that arise just from handling the muddled out-of-network care. The insurers are forcing upon us even more of their primary product – administrative services – while evading the very purpose of health care coverage by not paying for medical services that the patient needs.

If we had a single payer national health program with first dollar coverage (like many other nations with much lower health care costs) then this out-of-network nonsense would go away. What is really perplexing is why haven’t our people demanded this before now? Don’t facts matter?

In fairness, when we, as experts, think of how much effort we have to put in just to understand these issues, it is no wonder the the insurers and the rest of the medical-industrial complex have been so successful in bamboozling the public at large. We can use the political process to overcome this, but it would require a massive effort. After a couple of decades of working on this, I don’t see it happening. Prove me wrong.

“42,000 Canadians come to the United States for care” – Really?

Posted by on Monday, Mar 17, 2014

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.

Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”

Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014

Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.

http://www.help.senate.gov/imo/media/doc/Pipes.pdf

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Frasier Institute Reports:

Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

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Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States

By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002

Abstract

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://content.healthaffairs.org/content/21/3/19.abstract

Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.

Warning: The following is wonkish

As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):

12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

In another province? ______ % Outside of Canada? ______ %

Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.

Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.

But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.

Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.

For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.

They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”

Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.

More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.

In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.

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For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.

More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:

http://www.cihi.ca/CIHI-ext-portal/internet/EN/subtheme/health+system+pe…

‘Innovation’ in health insurance plans

Posted by on Saturday, Mar 15, 2014

By Samuel Metz, M.D.

In a recent commentary at the JAMA Forum titled “The Innovation vs Consumer Protection Tug-of-War in Health Policy” [1], health economist Austin Frakt reflects on the possible sacrifice of innovation created by a single payer, universal health care plan.

“Greater regulation constrains choices, but may, in some ways, improve the options available and the choices people make,” he writes. “Market innovation encourages more options, including both helpful and harmful ones, and also allows more scope for people to make poor choices. A balance must be struck, and the left-right/protection-innovation tug-of-war that we see in health policy today reflects a debate about where to strike it.”

Dr. Frakt wonders whether consumers (his term) would be harmed or helped by a single payer plan that eliminates insurance plan innovation.

What consumers ultimately want from health care innovation is access, lower costs, and better health. When confronted with the unpredictability of human physiology and the complexity of our insurance options, consumers (we physicians call them patients) become intensely uncomfortable making choices that could lead to bankruptcy or an avoidable death of a family member if the wrong choice is made.

Professor Frakt is correct: when confronted by insurance packages with a bewildering variety of benefits, premiums, co-pays, deductibles, and networks, patients usually choose badly. Overwhelmed by the responsibility to guess which future diseases might afflict their families, patients default to plans that appear to promote their short-term financial interest, but which later prove to be against their long-term financial (and medical) interests [2-4].

Single-payer systems eliminate insurance innovation. All patients must accept one plan (single payer) with one risk pool (human beings), one set of benefits (all treatable conditions receive treatment), and one network (all physicians).

In return for sacrificing insurance innovation, patients participate in a health care system with guaranteed access, lower costs, and the best health care outcomes. This is not conjecture: for every population in which it is used, single-payer systems provide better care to more people for less money than American private insurance [5].

Professor Frakt summarizes this well when he observes that innovation includes both helpful and harmful choices. By eliminating insurance innovation, single payer removes the most terrifying choice most patients (and consumers) will ever confront. It would be a rare patient indeed who yearns for the good old days of insurance innovation.

References
1.    Frakt, A. JAMA Forum: “The Innovation vs Consumer Protection Tug-of-War in Health Policy.” New@JAMA, March 12, 2014.
2.    Abaluck J, Gruber J. “Choice Inconsistencies among the Elderly: Evidence from Plan Choice in the Medicare Part D Program.” American Economic Review, 2011;101(4): 1180-1210.
3.    Zhou C, Zhang Y. “The Vast Majority Of Medicare Part D Beneficiaries Still Don’t Choose The Cheapest Plans That Meet Their Medication Needs.” Health Affairs 2012;31(10): 2259-2265.
4.   “The Health Insurance Experiment. A Classic RAND Study Speaks to the Current Health Care Reform Debate.” Rand Research Highlights. 2006. http://www.rand.org/content/dam/rand/pubs/research_briefs/2006/RAND_RB9174.pdf. accessed February 25, 2014.
5.    Davis K, Schoen C, Schoenbaum SC, Doty MM, Holmgren AL, Kriss JL, Shea KK. “Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care,” The Commonwealth Fund, May 2007. http://www.commonwealthfund.org/Publications/Fund-Reports/2007/May/Mirror–Mirror-on-the-Wall–An-International-Update-on-the-Comparative-Performance-of-American-Healt.aspx. Accessed March 12, 2014.

Dr. Samuel Metz is a Portland anesthesiologist and a member of Physicians for a National Health Program and Mad As Hell Doctors, both advocates for single-payer health care, and of Health Care for All Oregon, an umbrella organization advocating for publicly funded universal care for all Oregonians.

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