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.
Trump: ObamaCare replacement coming in ‘a couple of weeks’
By Max Greenwood
The Hill, February 18, 2017
President Trump said on Saturday that a plan to replace the Affordable Care Act will come “in a couple of weeks.”
“We are going to be submitting in a couple of weeks a great healthcare plan that’s going to take the place of the disaster known as ObamaCare,” he said at a campaign rally in Melbourne, Fla. “It will be repealed and replaced.”
“Just so you understand, our plan will be much better healthcare at a much lower cost,” he added.
Trump: Tax reform plan is ‘very well finalized’ but will come after ACA repeal
By Jacob Pramuk
CNBC, February 22, 2017
President Donald Trump said Wednesday that a Republican tax reform plan is nearly done but reiterated it will come after an Affordable Care Act repeal measure.
“Before we do the tax — which is actually very well finalized — but we can’t submit it until the health care statutorily or otherwise,” Trump told reporters before a White House budget meeting. “So we’re doing the health care — again moving along very well — sometime during the month of March, maybe mid-to-early March, we’ll be submitting something that I think people will be very impressed by.”
Health care reform is going to happen right now. This week members of Congress in town hall meetings throughout the nation are facing thousands of angry citizens who are demanding single payer reform. Wait a minute. Is that right?
Not exactly. The message that they are hearing is they do not want to lose the benefits of the Affordable Care Act but rather they want something better.
Where is that resounding voice of the people demanding single payer reform? President Trump needs to see the new article published this week in the Annals of Internal Medicine that shows him how he actually can provide his wish of “much better healthcare at a much lower cost.” But he will never see the article if we don’t make enough noise to penetrate the right-wing guard that is surrounding him.
The article he needs to see immediately:
By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
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.
Future life expectancy in 35 industrialised countries: projections with a Bayesian model ensemble
By Vasilis Kontis, PhD, James E Bennett, PhD, Colin D Mathers, PhD, Guangquan Li, PhD, Kyle Foreman, PhD, Prof Majid Ezzati, FMedSci
The Lancet, February 21, 2017
Projections of future mortality and life expectancy are needed to plan for health and social services and pensions. Our aim was to forecast national age-specific mortality and life expectancy using an approach that takes into account the uncertainty related to the choice of forecasting model.
We developed an ensemble of 21 forecasting models, all of which probabilistically contributed towards the final projections. We applied this approach to project age-specific mortality to 2030 in 35 industrialised countries with high-quality vital statistics data. We used age-specific death rates to calculate life expectancy at birth and at age 65 years, and probability of dying before age 70 years, with life table methods.
Life expectancy is projected to increase in all 35 countries with a probability of at least 65% for women and 85% for men. There is a 90% probability that life expectancy at birth among South Korean women in 2030 will be higher than 86·7 years, the same as the highest worldwide life expectancy in 2012, and a 57% probability that it will be higher than 90 years. Projected female life expectancy in South Korea is followed by those in France, Spain, and Japan. There is a greater than 95% probability that life expectancy at birth among men in South Korea, Australia, and Switzerland will surpass 80 years in 2030, and a greater than 27% probability that it will surpass 85 years. Of the countries studied, the USA, Japan, Sweden, Greece, Macedonia, and Serbia have some of the lowest projected life expectancy gains for both men and women. The female life expectancy advantage over men is likely to shrink by 2030 in every country except Mexico, where female life expectancy is predicted to increase more than male life expectancy, and in Chile, France, and Greece where the two sexes will see similar gains. More than half of the projected gains in life expectancy at birth in women will be due to enhanced longevity above age 65 years.
There is more than a 50% probability that by 2030, national female life expectancy will break the 90 year barrier, a level that was deemed unattainable by some at the turn of the 21st century. Our projections show continued increases in longevity, and the need for careful planning for health and social services and pensions.
UK Medical Research Council and US Environmental Protection Agency.
From the Discussion
By contrast, projected life expectancy is lower in countries with higher levels of young adult mortality and major chronic disease risk factors, and possibly less effective health systems. These countries also tend to have higher social inequalities, which might lower national life expectancy by affecting the entire population or through the poor health of the worst-off social groups and communities, which in turn affects the national average. Notable among poor-performing countries is the USA, whose life expectancy at birth is already lower than most other high-income countries, and is projected to fall further behind such that its 2030 life expectancy at birth might be similar to the Czech Republic for men, and Croatia and Mexico for women. The USA has the highest child and maternal mortality, homicide rate, and body-mass index of any high-income country, and was the first of high-income countries to experience a halt or possibly reversal of increase in height in adulthood, which is associated with higher longevity. The USA is also the only country in the OECD without universal health coverage, and has the largest share of unmet health-care needs due to financial costs. Not only does the USA have high and rising health inequalities, but also life expectancy has stagnated or even declined in some population subgroups. Therefore, the poor recent and projected US performance is at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.
This study predicts an increase in life expectancy for 35 industrialized nations but notes that the recent and projected performance in the United States is poor. That is “at least partly due to high and inequitable mortality from chronic diseases and violence, and insufficient and inequitable health care.”
More diligent application of beneficial public policies would improve our outcomes. Particular notable is the inequitable health care in our country. It is not that we lack sufficient funds. We are already spending $3.2 trillion – more than enough to provide quality health care for all. It is rather that we fail to elect individuals who understand and would support public policies that would make this a better nation.
This is shameful. We could act to change our course, but we, as a nation, have accepted mediocrity instead.
The Republicans’ campaign promises are coming back to haunt them as they confront the reality of dealing with a law that is supported by at least half of the population. The debate among Republicans in Congress over how to deal with the GOP’s promise to repeal and replace the Affordable Care Act (ACA) is splitting the party. While there is consensus to repeal it at the earliest possible time, there is great concern that the political fallout of doing so without an acceptable replacement plan will lead to dire political consequences. Whatever the GOP does, or does not do, Democrats can rightly claim that the Republicans will own the results as “Trump Care,” and pay for it in the 2018 and 2020 election cycles.
Although there is not yet a firm GOP replacement plan, it is likely to include replacement of the ACA’s tax subsidies with tax credits, shift more costs to patients, remove the individual mandate, limit annual caps, permit skimpier insurance plans, and shift responsibility to the states through block grants for decisions about health care coverage.(1) Other likely components of the GOP plan will be expansion of health savings accounts, selling insurance across state lines, expansion of high-risk pools (all of which have largely failed in recent years), and further privatization of Medicare and Medicaid.
Outright full repeal of the ACA would eliminate two of the most popular parts of the ACA: the requirement that insurers cannot deny coverage based on pre-existing conditions and allowing children to be covered on their parents’ coverage until age 26. That may call for follow-up legislation addressing these needs. The Centers for Medicaid & Medicaid Services (CMS) are giving Republicans a gift by their new proposed rule for 2018 giving states more authority to determine level of coverage, set rules for adequacy of networks, and change enrollment procedures, all of which benefit insurers more than patients. (2)
The downsides of outright repeal of the ACA are obvious: throwing some 20 million people off of health insurance, and easing constraints on insurers who will charge what the market will bear, reduce coverage and choice through tighter networks, issue more barebones policies, avoid sicker enrollees, and further withdraw from unprofitable markets. All of the GOP plans will shift more responsibility to the states for Medicaid with less funding and whatever exchange offerings may remain on the individual market.
In order to come up with a sustainable health care plan that meets the needs of Americans for affordable and accessible health care, we need to learn from experience and evidence from the past. While the ACA brought improved access for 20 million people, especially through expansion of Medicaid, it has failed to rein in costs after seven years and there is no cost containment in sight. The problems, of course, go back more than two decades before the ACA, including the failure of the insurance market, the lack of enough competition, and segmentation of risk pools to the benefit of insurers. Private insurers are starting to admit that they are on a death march without continued and more generous public funding.
We have learned that privatization results in less efficiency, higher overhead, profiteering, and worse care, whether privatization of Medicare or Medicaid. Further deregulation of health care will just add to our problems. Legislators are being held hostage to the insurance and drug industries as lobbyists win the day within the Beltway and in state capitols.
We have to ask who the health care system is for—patients and families or corporate interests that feed off the backs of sick people and taxpayer money. If the GOP pursues its claimed conservative principles, such as maximizing efficiency and choice, enhancing value, lowering costs, and reining in excess bureaucracy, another alternative is in plain sight, which supports these principles—single-payer national health insurance (NHI). Enactment of NHI would bring universal access to health care for all 320 million Americans in a sustainable way with these benefits:
This is a pivotal time for both political parties and the country, with far-reaching consequences into the future. Any GOP replacement or repair plan will fail, be unsustainable, and incur huge and unaffordable costs for taxpayers without the benefits that Americans need and deserve. The winners would be the private insurance industry, the drug industry, other corporate stakeholders in the medical industrial complex, and Wall Street. The losers would be patients and their families, who will have less access, choice, and affordable care, and face worse health outcomes. States would gain authority but lose by massive cuts in federal funding for health care. In the long run, the Republican Party will be a loser in future election cycles as they face a huge public backlash over their “reform” plan.
The first political party to enact NHI will govern for many years to come. It is an open question which party will realize that first.
Adapted in part from my forthcoming book, Crisis in U.S. Healthcare: Corporate Power vs. the Common Good, to be released by Copernicus Healthcare on March 15, 2017. (5)
John Geyman, M.D. is the author of The Human Face of ObamaCare: Promises vs. Reality and What Comes Next and How Obamacare is Unsustainable: Why We Need a Single-Payer Solution For All Americans
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.
Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs
By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Annals of Internal Medicine, Ideas and Opinions, February 21, 2017
Although Republicans’ proposals seem unlikely to achieve President Trump’s triple aim — more coverage, better benefits, and lower costs — single-payer reform could. Such reform would replace the current welter of insurance plans with a single, public plan covering everyone for all medically necessary care — in essence, an expanded and upgraded version of the traditional Medicare program.
Savings Available to Expand and Improve Coverage Under Single-Payer Reform, 2017
220.0 – Insurance overhead and administration of public programs
149.3 – Hospital administration and billing
75.3 – Physicians’ office administration and billing
503.6 – Total administration
113.2 – Outpatient prescription drugs
616.8 – Total administration plus outpatient prescription drugs
This morning (Feb 21) AIM decided to allow free access to this article:
Single-payer reform is ‘the only way to fulfill the president’s pledge’ on health care: Annals of Internal Medicine commentary; Researchers estimate administrative savings at $504 billion annually
Physicians for a National Health Program, Press Release, February 21, 2017
Proposals floated by Republican leaders won’t achieve President Trump’s campaign promises of more coverage, better benefits, and lower costs, but a single-payer reform would, according to a commentary published today [Tuesday, Feb. 21] in Annals of Internal Medicine, one of the nation’s most prestigious and widely cited medical journals.
Republicans promised to repeal the Affordable Care Act on the first day of the Trump presidency. But the health reform effort has stalled because Republicans in Congress have been unable to come up with a better replacement and fear a backlash against plans that would deprive millions of coverage and raise deductibles.
In today’s Annals commentary, longtime health policy experts Drs. Steffie Woolhandler and David Himmelstein warn that the proposals by Speaker Paul Ryan, R-Wis., and Secretary of HHS Tom Price would slash Medicaid spending for the poor, shift the ACA’s subsidies from the near-poor to wealthier Americans, and replace Medicare with a voucher program, even as they would cut Medicare’s funding and raise the program’s eligibility age.
Woolhandler and Himmelstein review evidence that, in contrast, single-payer reform could provide comprehensive first-dollar coverage to all Americans within the current budgetary envelope because of vast savings on health care bureaucracy and profits. The authors estimate that a streamlined, publicly financed single-payer program would save $504 billion annually on health care paperwork and profits, including $220 billion on insurance overhead, $150 billion in hospital billing and administration and $75 billion doctors’ billing and paperwork. They estimate that an additional $113 billion could be saved each year by hard bargaining with drug companies over prices. A table in the paper summarizes these savings.
The savings would cover the cost of expanding insurance to the 26 million who remain uninsured despite the ACA, as well as “plugging the gaps in existing coverage – abolishing copayments and deductibles, covering such services as dental and long-term care that many policies exclude.”
The lead author of the commentary, Dr. Steffie Woolhandler, is an internist, distinguished professor of public health and health policy at CUNY’s Hunter College, and lecturer in medicine at Harvard Medical School. She said: “We’re wasting hundreds of billions of health care dollars on insurance paperwork and profits. Private insurers take more than 12 cents of every premium dollar for their overhead and profit, as compared to just over 2 cents in Medicare. Meanwhile, 26 million are still uninsured and millions more with coverage can’t afford care. It’s time we make our health care system cater to patients instead of bending over backward to help insurance companies.”
Dr. David Himmelstein, the senior author, is a primary care doctor and, like Woolhander, a distinguished professor at CUNY’s Hunter College and lecturer at Harvard Medical School. He noted: “We urgently need reform that moves forward from the ACA, but the Price and Ryan plans would replace Obamacare with something much worse. Polls show that most Americans – including most people who want the ACA repealed, and even a strong minority of Republicans – want single-payer reform. And doctors are crying out for such reform. The Annals of Internal Medicine is one of the most respected and traditional medical journals. Their willingness to publish a call for single payer signals that it’s a mainstream idea in our profession.”
The Annals of Internal Medicine is the flagship journal of the American College of Physicians (ACP), the nation’s largest medical specialty organization with 148,000 internal medicine physicians (internists), related subspecialists, and medical students. In 2007, the Annals published a lengthy policy article in which the ACP said a single-payer system was one pathway to achieving universal coverage. In early 2008, the journal published a study showing 59 percent of U.S. physicians support “government legislation to establish national health insurance,” a leap of 10 percentage points from five years before.
Today’s commentary is believed to be the first full-length call for single payer, or national health insurance, that the journal has published in its 90-year history.
There are two reasons why this article from the Annals of Internal Medicine is so important.
As the Democrats proved with ACA and the Republicans are now learning by coming up essentially empty handed in their search for reform that would meet President Trump’s goal of more coverage, better benefits, and lower costs, building on our fragmented multi-payer system cannot possibly meet these goals. This article explains why the Republicans, working with the Democrats, need to turn to the single payer model if they wish to achieve President Trump’s admirable goals (“insurance for everybody… much less expensive and much better,” Washington Post, January 15, 2017). With the reform process currently taking place, this article could not be more timely.
The other reason this is important is that it represents an acknowledgement of the editors of the Annals of Internal Medicine – a publication of the American College of Physicians – that single payer needs to be a prominent part of the national dialogue on reform. In fact, today (Feb 21) the article was featured as a banner headline on the opening page of the journal’s website. Those who read the major medical journals regularly understand what a breakthrough this is.
Today is the day. The time has come to steamroller all of the other vacuous policy proposals on health care reform and mount the flag of health care justice for all in America. Begin by distributing widely the article, “Single-Payer Reform: The Only Way to Fulfill the President’s Pledge of More Coverage, Better Benefits, and Lower Costs,” (link above).
Actuarial Challenge: Announcement of Round One Results
Robert Wood Johnson Foundation
The Actuarial Challenge, sponsored by the Robert Wood Johnson Foundation (RWJF), brings actuaries together to explore approaches to stabilize the individual health insurance market. The Challenge is administered by Milliman, Inc. and actively promoted by the American Academy of Actuaries and the Society of Actuaries. Support for the Actuarial Challenge is being provided by the Robert Wood Johnson Foundation.
The Challenge kicked off in late September. Almost 70 participants registered, comprising 20 teams. Initial papers were submitted by December 9th. The papers each presented a proposal of various ways in which the individual health insurance market could be reformed. The proposals were not intended to be comprehensive, but to offer ideas on different ways to improve certain aspects of the current system. A panel of five judges (all actuaries) reviewed each paper and ultimately selected five papers to move on to the next round. Round Two involves the selected teams working with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market.
Round Two Proposals
Individual Market Redux
Revises rating to allow a wider premium range by age (5-to-1) and limited consideration of an enrollee’s health status in setting premium rates via an automated process (up to an additional 50% of premium). Uses contributions to individual health savings accounts for mid/low income consumers to replace premium and cost sharing subsidies. Revises risk adjustment methodology and restores a reinsurance mitigation program. Uses Medicaid reimbursement levels and increases health cost transparency. Increases penalties for not obtaining health insurance, but allows more benefit plan design flexibility. Reduces mandated benefits based on scientific evidence and use of an independent board. Incentivizes payment reform, integration of healthcare information, implementation of clinical best practices, and value-based care.
Why Not BE HIP?
Establishes a nationwide Basic Essential Health Insurance Plan (BE HIP) covering a core set of services/benefits set by federal regulation. Allows purchase of state regulated standardized supplemental plans (benefit riders) to offset cost sharing (i.e., upgrade to richer benefits). Automatic enrollment and/or penalty of full cost of basic plan if not enrolled. Uses a risk adjustment program and reinsurance to protect insurers. Premium equalization process to account for socioeconomic variations between insurers in a given market. Premium subsidies use similar methodology as the Patient Protection and Affordable Care Act (ACA), although percentages may differ.
All residents receive a fully publicly-funded preventive plan and must purchase an insurance plan for non-preventive services. Insurers must offer a standard plan but may offer additional plans subject to state regulations such as actuarial soundness, minimum coverage levels and loss ratios. Premiums will be limited to significantly lower and more affordable levels. A simplified, permanent publicly funded risk mitigation program based on reinsurance formulas will result in reduced premium. Hospital costs will be reduced by payment at Medicare reimbursement levels. Drug costs will be lowered by allowing purchase from qualified international locations. Simplified low-income premium discounts will be available. Penalties equal to the lowest cost insurance plan will apply for non-coverage. Lifetime universal Medical ID cards will be used to monitor enrollment, provide electronic medical records, and act as low-interest credit cards to pay for premiums and out-of-pocket medical expenses. Exchanges will act simply as informational websites.
Uses auto enrollment into newly defined catastrophic plans to enforce participation, and combines the individual and small group markets (with no self-funding allowed in the small group market). Consumer can add benefits through purchase of supplemental benefit riders. Block funds for subsidies provided from federal to state for the state to administer. Elimination of dual regulation to reduce expenses. Allows wider rating for age (5-to-1) and lowers or eliminates minimum medical loss ratios. Continues risk adjustment and restores reinsurance for up to five years. The equivalent of cost-sharing reduction (CSR) funds would be deposited into a consumer’s health savings account (HSA), if eligible. Use reference-based benefit pricing for provider fees. Encourages risk contracting with both upside and downside risk to the provider. Eliminates direct-to-consumer advertising. Eliminates grandfathered and transitional business. Focuses on consumer accountability by providing consumers with improved cost transparency and other resources to help them make educated decisions regarding their healthcare.
King of Carrot Flowers
Creates three pools in the individual market: (1) Over 250% FPL (federal poverty level) with state regulated underwritten market, (2) Under 250% FPL with federally funded underwritten and subsidized market, and (3) Special Needs (High Risk) Pool with a federally-funded, highly-subsidized market for individuals with persistent high costs or uninsurable conditions. Guarantee issue, but requires continuous enrollment. Incentivizes providers to manage care. Encourages tax parity between individual and group market by capping group tax deductions. Allows more tax-favored health savings account contributions.
Milliman will work with these five selected teams to model their proposals in February and March. The five Round Two teams will be able to incorporate the modeling results in their final papers.
Nine other teams have the opportunity to refine their papers for possible exposure on the Actuarial Challenge website (which is hosted by the American Academy of Actuaries) or as decided by the RWJF at the end of the Challenge.
The Mod Squad
Increases incentives to first-time enrollees, but with significant penalties for not obtaining coverage after first year…
JHU Actuarial Club
Provides enhanced benefits (e.g., gym membership, fitness classes, preventive services, etc.) in insurance coverage to encourage younger individuals to purchase…
Policy Proposal for Healthy Behavior Incentive (“HBI”) Plans
Healthy Behavior Incentive Plans encourage a partnership between the insured, insurer, and health care provider to maintain well-being rather than just reimbursement for expenditures…
Underwriting and Premium Rating using Risk Adjustment
Focuses on improving market stability through increased enrollment of lower cost individuals by revising the rating basis to better align with expected costs…
Increases individual market penalties to encourage more enrollment by young and healthy uninsured, and mitigate developing anti-selection spiral in the individual market…
Team ACA Version 2.0
Proposes changes to the subsidy and risk adjustment programs…
Consulting Actuaries for Sustainable Healthcare
Insurance reforms to improve actuarial soundness, and provider price & quality reforms, to address unsustainable underlying healthcare spending…
Develops actuarial incentive compensation for physicians who are effective at addressing the underlying cause of patient health conditions by using the “food as medicine” concept…
A Social Insurance Solution To Health Care Finance
Proposes to use a social insurance model to replace all current health insurance (across all markets). Covers all legal residents in the program through a payroll tax for funding. Insurance plan would cover preventive care and catastrophic care (exceeding 7.5% of income). Low income families would receive additional assistance similar to Supplemental Nutrition Assistance Program (SNAP) benefits. Routine care would be funded by individuals, but administered through a central fund, billing patients as with a credit card. Administrators must negotiate with providers, but must make all fees available to the public.
About the Actuarial Challenge:
In designing a health care financing system that is efficient and effective in ensuring affordable access to health care, it seems that the nation’s actuaries should be up to the task. So it is informative to see what recommendations were elicited when the Robert Wood Johnson Foundation, assisted by Milliman, Inc., issued the Actuarial Challenge, calling for an exploration of approaches to stabilize the individual health insurance market.
Of the proposals submitted, five were selected to move into the second round to work with Milliman to model their proposals to illustrate the potential financial impact on the individual health insurance market. Although some proposals would introduce improvements into the individual insurance market, they all would increase administrative complexity and none would ensure affordable coverage for all participants in the individual market.
Nine other proposals were selected for possible posting on the Actuarial Challenge website, although they do no move into round two. They too are quite disappointing except for one proposal – A Social Insurance Solution To Health Care Finance – that seems to acknowledge the importance of a universal system. Though even that proposal requires cash payments for all routine care except preventive care and catastrophic care charges exceeding 7.5% of income. We have plenty of studies to show that the excessive out-of-pocket costs of this model would leave too many people broke and without the care they need.
Except for the social insurance model, the authors of the proposals limited themselves to solutions for the individual market – a relatively small sector of health care – which is understandable since that was the challenge they were given.
There are two predominant disappointments with the submissions for this challenge. The first is that it should be intuitive that the problems of the individual market cannot be resolved with patches limited to that market. The solutions require a fundamental change of the financing infrastructure of our entire health care system, and the actuaries should acknowledge that in their proposals.
The other disappointment is in the nature of the various recommendations. They seem to lack a sensitivity to the imperative to address issues of health care justice, ensuring an equitable system to bring affordable care to everyone, whether just in the individual market or throughout the entire system – the latter actually being the moral imperative.
The model that would work is already well understood – a single payer national health program, aka an improved Medicare for all. Maybe we can teach the actuaries something, though it would be difficult. I will say that I once was a speaker at a national meeting of actuaries, and I did find that there was some insight amongst the members, but that didn’t translate into policy recommendations.
Scheme Tied to UnitedHealth Overbilled Medicare for Years, Suit Says
By Mary Williams Walsh
The New York Times, February 16, 2017
UnitedHealth Group, one of the nation’s largest health insurers, is accused in a scheme that allowed its subsidiaries and other insurers to improperly overcharge Medicare by “hundreds of millions — and likely billions — of dollars,” according to a lawsuit made public on Thursday at the Justice Department’s request.
The accusations center on Medicare Advantage, a program through which people 65 or older agree to join private health maintenance organizations, or H.M.O.s, whose costs the government reimburses.
The program was created in 2003 after UnitedHealth and other insurers said that managed care could help contain the overall cost of Medicare, which has strained the federal budget by rising faster than the rate of inflation.
Instead of slowing Medicare costs, UnitedHealth may have improperly added excess costs in the billions of dollars over more than a decade, according to the lawsuit, which was unsealed in Federal District Court in Los Angeles.
The newly public accusations were first made in 2011, when a former UnitedHealth executive, Benjamin Poehling, filed a complaint under the False Claims Act, a federal law that allows private citizens to take legal action when they believe a government program has been defrauded.
The Justice Department’s court notice that it was joining the case involving UnitedHeath was filed by Chad Readler, a lawyer who joined the agency’s civil division as part of the Trump administration.
Mr. Poehling was finance director for UnitedHealthcare Medicare and Retirement, a subsidiary that works with the Medicare Advantage program. His complaint describes “a corporate culture that demands and rewards financial success from its employees,” including initiatives to increase a billing practice known as “risk adjustment.”
Mr. Poehling said that he and other employees were given “risk adjustment” targets and their performance was evaluated based on how well they achieved them.
Attached to his complaint was an email message from his division’s chief financial officer, Jeffrey J. Knutson, urging staff members “to really go after the potential risk scoring that you have consistently indicated is out there.”
“Let’s turn on the gas!” Mr. Knutson wrote. “What can we do to make sure we are being reimbursed fairly for the members and risk we take on more than what we are currently doing.
“When we meet next on our steering committee, I’d like to see what it would take to add another $100M to our 2008 revenue from where we are. What would be doable? What resources would you need? What technology would you need?”
Medicare initially paid the H.M.O.s a fixed rate per member, no matter what chronic conditions members had. That made the H.M.O.s avoid signing up unhealthy people, because they required more care, reducing the companies’ profits.
The approach changed in 2003, when the Centers for Medicare and Medicaid Services added a “risk adjustment factor” to its reimbursement schedules for managed care. That made H.M.O.s more willing to sign up unhealthy people, but it also gave them a new incentive: to make people appear sicker than they were. UnitedHealth had a unit that helped its subsidiaries and other insurance companies perform risk adjustment calculations.
Medicare Advantage’s rules require that for patient care to qualify for risk adjustment factors, a patient’s condition must be verified in person on a regular basis by a qualified professional.
But Mr. Poehling said that coding specialists would instead mine patient records, looking for hints of a possible long-term condition. When they found one, they would request the higher payment without going through the required in-person evaluation.
The realization that medical records could be mined for extra money appears to have given rise to a cottage industry of consulting firms offering to screen patient histories and look for indications of long-term health problems that could be used to increase Medicare reimbursements.
Innumerable studies that we’ve written about have shown that the private Medicare Advantage plans have gamed the system at the expense of taxpayers by surreptitiously selectively enrolling healthier, less costly patients, and then, when risk adjustment was introduced to correct for this favorable selection, the plans upcoded to qualify for higher payments by making the patients appear sicker than they really were.
Finally, the legal system has caught up with them. First a whistleblower suit was filed under the False Claims Act, and now, under the Trump administration, the Justice Department has joined in that action.
UnitedHealth contends that they complied with the program rules. Technically, that may be true. The Bush and Obama administrations along with Congress were complicit with efforts to ensure success of the private Medicare Advantage plans as a first step toward eventually privatizing the Medicare program. Insurance innovation has been praised by the privatizers. In this instance, innovation is enhanced by interpreting quite loosely the federal regulations on favorable selection and risk adjustment.
We need a little perspective here. There is no question that the insurers manipulated the system to gain a greater return than the actual health of their enrollees warranted. But private for-profit corporations have a responsibility to their shareholders to do precisely that – maximize returns – and they will every time.
Whether or not there is a technical violation of the regulations, it is the insertion of a rent-seeking intermediary that is the fundamental flaw here. Gaming favorable selection and risk adjustment does not occur in the traditional Medicare program. Gaming the system is expensive because it requires more administrative efforts to pull it off. The private plans have about five times the administrative costs of the traditional Medicare program, and we taxpayers are footing the bill.
The inferiority of the private Medicare plans is not a newly discovered fact. My very first Quote of the Day (before I realized what I was starting) was Congressman Pete Stark’s response to Karen Ignagni of AAHP (precursor to AHIP) who was boasting about Medicare + Choice plans (precursor to Medicare Advantage). She said that the the early results of the plans provided proof that the private sector could provide higher quality at lower costs. (In fact the evidence was the opposite in that Medicare + Choice plans soon began to pull out of the market because they could not deliver on that promise. But the market was saved by converting to Medicare Advantage on terms much more favorable to the insurers.) Pete Stark, not known for mincing words, responded to Ignagni’s praise of private Medicare plans by saying, “She’s full of more s*** than a Christmas goose.”
Obviously the insurers violated what should have been the intent of the laws and regulations. But they will always do that if it accrues to their benefit. The solution is simple: throw them out, fix Medicare, and then expand it to include all of us. An immediate benefit is that it would also end discussion of all of the flawed policies being considered under repeal and replace.
National Health Expenditure Projections, 2016–25: Price Increases, Aging Push Sector To 20 Percent Of Economy
By Sean P. Keehan and colleagues at the CMS Office of the Actuary
Health Affairs, February 15, 2017
Under current law, national health expenditures are projected to grow at an average annual rate of 5.6 percent for 2016–25 and represent 19.9 percent of gross domestic product by 2025. For 2016, national health expenditure growth is anticipated to have slowed 1.1 percentage points to 4.8 percent, as a result of slower Medicaid and prescription drug spending growth. For the rest of the projection period, faster projected growth in medical prices is partly offset by slower projected growth in the use and intensity of medical goods and services, relative to that observed in 2014–16 associated with the Affordable Care Act coverage expansions. The insured share of the population is projected to increase from 90.9 percent in 2015 to 91.5 percent by 2025.
Over this decade, with no further changes in our health care financing system, national health expenditures are expected to increase to one-fifth of our GDP. Unfortunately, our current health care financing system remains incapable of containing health care costs.
Perhaps more alarming is that this decade will reduce the numbers of uninsured by only six-tenths of one percent. Eight and one-half percent of the population will remain uninsured in 2025. Without change, our system will continue to fail to ensure that health care is a right for all.
On a personal note, our daughter-in-law is in Taiwan – her native country – where today she had major surgery for cancer. All went well.
Our son just sent a photo of the mission statement that is posted on the wall of her post-op room.
Objective: To promote the basic human right of health
If only President Trump and his colleagues in the District of Columbia truly supported that concept and would act upon it…
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
Centers for Medicare & Medicaid Services (CMS), Press release, February 15, 2017
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients. This proposed rule would make changes to special enrollment periods, the annual open enrollment period, guaranteed availability, network adequacy rules, essential community providers, and actuarial value requirements; and announces upcoming changes to the qualified health plan certification timeline.
“Americans participating in the individual health insurance markets deserve as many health insurance options as possible,” said Dr. Patrick Conway, Acting Administrator of the Centers for Medicare & Medicaid Services. “This proposal will take steps to stabilize the Marketplace, provide more flexibility to states and insurers, and give patients access to more coverage options. They will help protect Americans enrolled in the individual and small group health insurance markets while future reforms are being debated.”
The rule proposes a variety of policy and operational changes to stabilize the Marketplace, including:
Special Enrollment Period Pre-Enrollment Verification: The rule proposes to expand pre-enrollment verification of eligibility to individuals who newly enroll through special enrollment periods in Marketplaces using the HealthCare.gov platform. This proposed change would help make sure that special enrollment periods are available to all who are eligible for them, but will require individuals to submit supporting documentation, a common practice in the employer health insurance market. This will help place downward pressure on premiums, curb abuses, and encourage year-round enrollment.
Guaranteed Availability: The rule proposes to address potential abuses by allowing an issuer to collect premiums for prior unpaid coverage, before enrolling a patient in the next year’s plan with the same issuer. This will incentivize patients to avoid coverage lapses.
Determining the Level of Coverage: The rule proposes to make adjustments to the de minimis range used for determining the level of coverage by providing greater flexibility to issuers to provide patients with more coverage options.
Network Adequacy: The proposed rule takes an important step in reaffirming the traditional role of states to serve their populations. In the review of qualified health plans, CMS proposes to defer to the states’ reviews in states with the authority and means to assess issuer network adequacy. States are best positioned to ensure their residents have access to high quality care networks. Also plans will now be required to include only one0fifth of essential community providers (ECPs) within their networks, removing from the patient the option of receiving care from the other four-fifths of ECPs.
Qualified Health Plan (QHP) Certification Calendar: In the rule, CMS announces its intention to release a revised proposed timeline for the QHP certification and rate review process for plan year 2018. The revised timeline would provide issuers with additional time to implement proposed changes that are finalized prior to the 2018 coverage year. These changes will give issuers flexibility to incorporate benefit changes and maximize the number of coverage options available to patients.
Open Enrollment Period: The rule also proposes to shorten the upcoming annual open enrollment period for the individual market. For the 2018 coverage year, we propose an open enrollment period of November 1, 2017, to December 15, 2017. This proposed change will align the Marketplaces with the Employer-Sponsored Insurance Market and Medicare, and help lower prices for Americans by reducing adverse selection.
CMS Proposed Rule:
CMS today released a new proposed rule allegedly designed to “protect patients” by stabilizing the plans offered in the ACA insurance exchanges. A cursory reading of the press release would tend to confirm this intent, but a careful reading of the release and especially the executive summary of the proposed rule will reveal that the rule is designed to improve the market for the insurers with a detrimental impact on potential enrollees of the insurance plans.
Revising the CMS rhetoric to match more accurately the actual impact on patients:
* Special Enrollment Period Pre-Enrollment Verification: Qualifying categories for special enrollment will be reduced, and documentation requirements increased. This will reduce the number of individuals with greater needs that the insurers would be required to accept outside of open enrollment – reducing adverse selection, but it will prevent many individuals who missed open enrollment because of the administrative burden from becoming insured.
* Guaranteed Availability: Insurers may apply premiums paid as a credit against unpaid premiums for the prior year, and then deny coverage because of non-payment for the current year. This will protect insurers from individuals who have difficulty paying the premiums, but at a cost of leaving individuals uninsured in spite of a good faith effort to pay current premiums.
* Determining the Level of Coverage: The insurers will be allowed greater flexibility in the variation of the actuarial values for the metal tiers. This greater flexibility will likely translate into less generous benefits for the beneficiary.
* Network Adequacy: The responsibility for regulatory oversight of network adequacy would be further shifted to the states. Although that would reduce the regulatory burden for the insurers, it would also threaten the adequacy of provider networks in states that have relaxed standards of how many physicians and hospitals would have to be included in the networks. Patients may find access to be impaired.
* Qualified Health Plan (QHP) Certification Calendar: Insurers would be allowed more time to incorporate benefit changes and maximize the number of coverage options available to patients. Allowing insurers more time to manipulate the benefits would allow them to reduce services more likely needed by the beneficiaries while increasing coverage for those services less likely to be used.
* Open Enrollment Period: The open enrollment period will be terminated six weeks earlier. This will protect insurers from many individuals with greater health care needs who often enroll later in the open period. This reduces adverse selection for the insurers but at a cost of leaving uninsured more individuals who have greater needs.
It is not only CMS that is catering to the insurers. Right now Congressional staff members are negotiating with representatives of the insurance industry to help write the replace and repair provisions promised by the politicians. It appears that the legislative proposals will be designed to protect and enhance the market for insurers, though at a cost of reducing the adequacy of coverage for the patients.
Why are we taking such good care of the insurers? We don’t even need them. We need a program that takes good care of patients – all patients. That would be an improved Medicare that includes everyone.
Moving Forward With Accountable Care Organizations
By Carrie H. Colla, PhD; Elliott S. Fisher, MD, MPH
JAMA Internal Medicine, February 13, 2017
During the past 4 years, we have made great strides in advancing our understanding of the changes that hospitals and physician groups implement in response to changes in payment and how providers perform under alternative payment models. Accountable care organization contracts, one type of alternative payment model, hold groups of health care professionals responsible for the cost and quality of care delivered to patients. Accountable care organization programs attract a diverse array of providers with differing legal and governance structures, varied contracts, and mixed capabilities that span service dimensions. These capabilities may include care management personnel and programs, adoption of advanced analytics (eg, to estimate the risk of hospitalization), or support for shared decision making. On average, ACO patients are spending modestly less on health care services and are associated with improved patient satisfaction and other patient-reported measures, with gains often concentrated in high-need, high-cost populations. Previous exposure to risk-bearing contracts, greater numbers of dually eligible or disabled patients, and higher initial financial benchmarks have been associated with greater savings. At the same time, these results mask variation in performance, with some ACOs saving while others spend over their benchmark following ACO formation. In addition, these modest savings have come at a net cost to the Medicare program (both program costs and shared savings rewards) and, although some quality measures have improved, many have not.
The research presented in this issue of JAMA Internal Medicine provides insights from 3 different ACO payment models: the Medicare Shared Savings Program (MSSP), Colorado’s Accountable Care Collaborative, and Oregon’s Coordinated Care Organizations. All 3 programs show some degree of success, although the results continue to be modest in magnitude.
These findings are relevant to 3 major considerations facing policymakers: (1) concerns about the harms of consolidation, (2) the amount of risk bearing needed to produce changes in behavior, and (3) how to manage potential conflicts between alternative payment models.
Consolidation between clinical providers, such as purchase of physician groups by hospital systems, and striking the proper balance between facilitating clinical integration and limiting market power is a major concern. Many believe that continued survival of independent practices is critical, yet economic incentives favor consolidation due to higher reimbursement for the same service in a hospital-based office compared with a physician office. Hospital-physician group consolidation can also raise prices in less-competitive commercial markets through increased bargaining power vis-à-vis insurers.
Accountable care organizations are defined by their accountability for the cost and quality of care, but the degree of accountability for spending varies dramatically across contracts. The amount of financial risk bearing necessary to achieve behavior change is an important area of inquiry, in part because so little is known. The incentives in most existing alternative payment models, including ACOs, are commonly considered insufficient to result in behavior change.
A third issue concerns potential conflicts between Medicare alternative payment models and the poorly understood interplay of incentives across these reforms. Currently, hospitals retain savings within inpatient-initiated bundles for patients attributed to an MSSP ACO. Although incentivizing value within a bundle, bundled payment models do not eliminate the incentive to provide more bundles. As the Centers for Medicare & Medicaid Services expands alternative payment models, it is possible that bundled payment programs will undermine overall savings.
In summary, we still have much to learn. Accountable care organizations have been established across diverse market settings, using a multitude of organizational structures and approaches to governance and operations, and this heterogeneity is reflected in the heterogeneity of their performance. The 2 articles published in this issue add to a growing body of evidence on overall performance, several dimensions of quality, and spending. Nevertheless, we know little about the effects of ACOs on patients’ health and quality of life. Perhaps most important for ACO leaders and the long-term success of these programs, we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts. Although the Centers for Medicare & Medicaid Services has conducted rigorous evaluations of the Pioneer program, generalizable findings tailored to organizational contexts are few. A long-term commitment to alternative payment model evaluation is necessary to ensure effective, sustainable payment and delivery system reform.
This lesson on accountable care, from the Dartmouth Institute, shows us that we still have much to learn. The respected authors state that a long-term commitment to alternative payment model evaluation is necessary. In the meantime, “we know little about the key ACO capabilities that are important to ensuring their success in different organizational or market contexts.”
We actually do have quite a bit of information, and it is unimpressive. What we cannot do is to allow a protracted course of many years or decades of studying accountable care to distract us from the urgent need to make changes that will ensure that everyone has affordable access to health care while dramatically reducing the profound administrative waste in our system.
The Affordable Care Act made some improvements, but not nearly enough as witnessed by the tens of millions uninsured and underinsured, by the failure to make health care affordable for too many of us, and by the perpetuation of the costly administrative excesses.
The next phase of reform being undertaken by our current Congress seems to be pending enactment of policies that would make markets work better for insurers but at a cost of leaving patients exposed to excessive out-of-pocket spending. They do not seem to be even pretending that accountability in shifting from volume to value is anything more than rhetoric (and the studies to date suggest this is true).
First things first. Let’s do what really works – enact a single payer national health program, an improved Medicare for all. It is a far better infrastructure to tease out data that might be used to actually improve quality while containing costs. But let’s not stall any longer on enacting the fundamental reform that we really need to make health care affordable for all of us.
Republicans, Aiming to Kill Health Law, Also Work to Shore It Up
By Robert Pear
The New York Times, February 12, 2017
After denouncing the Affordable Care Act as an abomination for seven years, Republicans in Congress, working with the Trump administration, are urgently seeking ways to shore up health insurance marketplaces created by the law.
While President Trump said as a candidate that “Obamacare is certain to collapse of its own weight,” Republicans fear such an outcome because, now that the fate of the health law is in their hands, they could be blamed by consumers and Democrats.
The administration is poised to issue a proposed regulation to try to stabilize insurance markets, and House Republicans are drafting legislation with a similar purpose. The regulation and the bills are intended to hold down insurance premiums and to lure insurers back into the public marketplaces from which they have withdrawn in the past couple of years.
There could not be better evidence that the Republicans never did have an effective plan to replace the Affordable Care Act than the fact that they are now advancing legislation to protect the private insurers in the ACA exchanges – reinforcing them rather than shutting them down.
So their strategy has changed from repeal and replace, and then to repeal and repair, and now simply to repair – repair that will protect the private insurers.
Many of the legislators are facing angry citizens at their town hall meetings who do not want to lose the health care benefits that they may have gained through ACA. That partially explains why they failed to deliver on their promise to “repeal Obamacare on day one.”
Many voters were supportive of repeal and replace, but the politicians and the voters had different objectives. The Republican politicians wanted to repeal the expansions of ACA and thereby reduce government spending on health care. Voters wanted changes (replacement) that would ensure that they could always receive health care that was affordable.
Considering this, it is understandable why the Republicans have not moved immediately forward with their replacement proposals. Reducing Medicaid funding through block grants would cause millions to lose their coverage. Switching Medicare to a voucher program would create greater financial burdens for Medicare beneficiaries. Changing market rules to promote bare-bones private plans is the Republican version of providing “access,” but that would make actual health care truly unaffordable for a majority of Americans with significant medical needs because the very high out-of-pocket expenses would be beyond the capabilities of most American family budgets.
The simmering anger is because ACA was inadequate for too many Americans, and it appears that the Republican “replace” proposals will leave millions worse off. The “replace” that people want is affordable health care, but not merely a continuation of the inadequate policies of the Affordable Care Act. What they really want, though some do not realize it, is an equitably funded, universal health insurance program – an improved Medicare for all. That would give all of us affordable access to health care, and not just access to nearly worthless private health plans.
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