Why I Oppose Payment Reform

By Alan Weil, Editor-in-Chief, Health Affairs
Health Affairs Blog, December 12, 2014

I had my epiphany shortly after I announced my departure from the National Academy for State Health Policy (NASHP) about nine months ago. In an effort to help find my successor, I contacted some executive search firms. One firm quoted what they referred to as the “market price.” When I pressed them to tell me how much effort this price represented, they declined to do so. Ultimately, I recommended that NASHP contract with a search firm that charged by the hour.

It was then that I realized that, given the choice between capitation (a fixed fee for the outcome I desired) and fee-for-service (an hourly rate with no accountability for the outcome), I, as a purchaser, chose fee-for-service. Only a hypocrite would go around talking about the importance of payment reform, while secretly conducting business the old way!

Having given the matter some further thought, I present my five reasons for opposing payment reform:

1. The premise of payment reform is flawed.

The major actors in today’s health care system have thrived in the old payment model, which rewards volume: filling beds, making referrals, conducting tests, and the like. We now say we want them to improve population health and clinical outcomes while holding down costs. Different competencies are required to achieve these different objectives. There is no reason to expect that the people and institutions that were successful under the old model are the best people and institutions to charge with carrying out the new model.

2. Payment reform is insufficiently disruptive.

As we capitate or bundle payments, these aggregated payments are generally given to the highest cost actor in the system: the hospital, health plan, or large medical practice that already has the most resources. We expect that, due to new incentives, they will share those resources with other, lower-cost professionals like dieticians, social workers, and community health workers, whose efforts may improve health outcomes. But this may be wishful thinking. Hospitals and health plans operate with inertia and under constraints that may prevent them from having what an observer might consider a rational response to the new incentives. Marginal changes in payment policy fail to disrupt the concentration of power held by expensive institutions, thereby limiting the likely effects.

3. There is no evidence to suggest that payment reform will achieve the goals we need it to achieve.

The Institute of Medicine tells us that 30 percent of health care spending is wasteful. Only nineteen of the original thirty-two Pioneer ACOs remain in the program, and only twelve are producing enough savings to be shared. Only 58 of the more than 200 participants in the Medicare Shared Savings Program are saving more than 2 percent. For all the effort we are putting into payment reform, at this point, we don’t have an evidence base that shows what we are doing will achieve the end result we desire.

4. The original rationale offered for payment reform doesn’t match the current objectives.

The current iteration of payment models began with integrated health systems, like Geisinger and Intermountain, complaining that they were financially penalized when they delivered high quality care. They had a point. Efforts to, for example, improve birth outcomes, yielded financial losses due to reduced revenue from Neonatal Intensive Care Units. Today’s narrative is that we need payment reform to leverage a system that is resistant to change to fundamentally alter the model of care. The original rationale required only that incentives be directionally correct — keep your savings when you invest in better quality. The more ambitious goal of payment reform opens up tremendous risks such as providers gaming quality metrics and avoiding complex patients. The payment reform movement has been hijacked to suggest it can accomplish things its founders never imagined.

5. Payment reform poses a risk for the growing understanding of the importance of patient-centered care.

Imagine the following scenario: three people come to the doctor with knee pain. Each person has their own goal for the outcome of their treatment: one wants to manage pain during her daily activities, one wants to play tennis again, and one wants be completely pain free. Now try and imagine a “value formula” for providers to achieve these three patient-centered outcomes. Even if you could come up with one, operationalizing it would be nearly impossible. And what provider would be willing to accept financial risk for achieving such varied patient goals? When we implement payment for “value” we oversimplify to make the methods administrable, but lose all nuance of patient preference.

Despite all of these reservations, I do not actually oppose payment reform. We all know current payment methods system are seriously flawed and that we can do better. But this list serves as a reminder that payment policy, like grass, is always greener on the other side.

http://healthaffairs.org/blog/2014/12/12/why-i-oppose-payment-reform/

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Comment:

By Don McCanne, MD

The health policy literature is saturated with expressions of the concept that we are no longer going to pay for health care based on the volume of care delivered, but rather we are going to start paying for quality instead. Traditional fee-for-service medicine encourages greater use of resources simply because that increases revenues. Innovations in payment reform are being proposed that supposedly will change fee-for-service to a system rewarding quality. Alan Weil, Editor-in-Chief of Health Affairs, provides us with insight on what those innovations might do.

Some of the proposals include accountable care organizations, pay for performance, bundling of payments, Medicare shared savings, capitation, and increased transparency combined with placing the upfront financial responsibility on patients so that they are forced to be better-informed shoppers. Each of these has its own problems and some could actually cause worse outcomes than our traditional fee-for-service system.

Perhaps the most important point that Weil makes is that those who have thrived on the volume-driven model are the same individuals we are asking to improve clinical outcomes while holding down costs. As he states, “There is no reason to expect that the people and institutions that were successful under the old model are the best people and institutions to charge with carrying out the new model.”

In the video at the following link, after presenting the five reasons for opposing payment reform, Weil suggests five elements that should be embraced when considering payment reform. I found them to be disappointing. For instance, he suggests that we should allow the leaders to lead and then follow them as we implement the payment reforms under a multi-payer system. He makes no attempt to distinguish these leaders from the MBAs who are already maximizing their business models while basically ignoring patient service concepts.

Perhaps more important is what is missing from Weil’s comments. He says absolutely nothing about concepts of social insurance, particularly the single payer model. Yet single payer would be far more effective in improving health care value than would any of the payment reforms under consideration today.

http://nyshealthfoundation.org/news-events/events/nyshealth-conference-payment-reform-expanding-the-playing-field

The Search For A National Child Health Coverage Policy

By Sara Rosenbaum and Genevieve M. Kenney
Health Affairs, December 2014

Abstract

Thirty-eight percent of US children depend on publicly financed health insurance, reflecting both its expansion and the steady erosion of employment-based coverage. Continued funding for the Children’s Health Insurance Program (CHIP) is an immediate priority. But broader reforms aimed at improving the quality of coverage for all insured children, with a special emphasis on children living in low-income families, are also essential. This means addressing the “family glitch,” which bars premium subsidies for children whose parents have access to affordable self-only employer-sponsored benefits. It also means addressing the quality of health plans sold in the individual and small-group markets—whether or not purchased through the state and federal exchanges—that are governed by the “essential health benefit” standard of the Affordable Care Act (ACA). In this article we examine trends in coverage and the role of Medicaid and CHIP. We also consider how the ACA has shaped child health financing, and we discuss critical issues in the broader insurance market and the need to ensure plan quality, including the scope of coverage, use of a pediatric medical necessity standard that emphasizes growth and development, the structure of pediatric provider networks, and attention to the quality of pediatric health care.

http://content.healthaffairs.org/content/33/12/2125.abstract

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The ACA’s Pediatric Essential Health Benefit Has Resulted In A State-By-State Patchwork Of Coverage With Exclusions

By Aimee M. Grace, Kathleen G. Noonan, Tina L. Cheng, Dorothy Miller, Brittany Verga, David Rubin and Sara Rosenbaum
Health Affairs, December 2014

Abstract

The Affordable Care Act (ACA) establishes essential health benefits as the coverage standard for health plans sold in the individual and small-group markets for all fifty states and the District of Columbia, including the health insurance Marketplaces. “Pediatric services” is one of the required classes of coverage under the ACA. However, other than oral health and vision care, neither the act nor the regulations for implementing it define what these services should be. We investigated how state benchmark plans—the base plan chosen in each state as the standard or benchmark of coverage in that state under ACA rules—address pediatric coverage in plans governed by the essential health benefits standard. Our review of summaries of all the state benchmark plans found that no state specified a distinct pediatric services benefit class. Furthermore, although benchmark plans explicitly included multiple pediatric conditions, many plans also specifically excluded services for children with special health care needs. The Department of Health and Human Services has made a commitment in the essential health benefits regulations to review its approach for the 2016 plan year. Thus, our findings have implications for future regulations regarding the essential health benefits standard for pediatric services.

http://content.healthaffairs.org/content/33/12/2136.abstract

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The Scheduled Squeeze On Children’s Programs: Tracking The Implications Of Projected Federal Spending Patterns

By C. Eugene Steuerle and Julia B. Isaacs
Health Affairs, December 2014

Abstract

Federal programs for children are under increasing budgetary pressure. According to current federal law or any budget alternative being offered by the president or congressional leaders, spending on children would decline as a share of the budget and of the national economy. This article summarizes past, current, and projected budgets for children’s programs. It traces significant historical expansions of means-tested programs, such as the Supplemental Nutrition Assistance Program; depicts fairly significant declines in more universal supports, such as the income tax exemption for dependents; and shows the future squeeze on children’s programs brought about by automatic growth in health, retirement, and tax subsidy programs, along with the failure of revenues to keep pace with the overall growth in spending. Federal programs for health care have been a mixed blessing for children: Medicaid has grown to be the largest federal support for children, but overall federal health care costs eat away at the share of the budgetary pie left for anything else.

http://content.healthaffairs.org/content/33/12/2214.abstract

Comment:

By Don McCanne, MD

During the health care reform process there seemed to be an attitude that we were already doing well in ensuring that the health care needs of children were being met. Employer-sponsored family coverage took care of middle- and upper-income children, Medicaid and SCHIP covered lower-income children, and community health centers and other safety-net institutions took care of children who were not covered by the other programs. The Affordable Care Act expanded assurances of coverage by providing income-based subsidies for plans offered through the exchanges. So what is the problem?

Having multiple sources of coverage with different eligibilities that change with continual changes in life circumstances – income levels, employment status of family income source, changes in geographical location, variations in community resources, citizenship status, etc. – results in instability of coverage for everyone, certainly including children. These articles from the current Health Affairs summarize some of these variations in the public and private programs, variations in benefits covered, and variations in financing of the programs. The current situation might be summed up as lacking “a national child health coverage policy” (Rosenbaum and Kenney).

Although many factors contribute to the deficiencies in child health coverage, one of the more important is that we continue to try to build upon a fragmented combination of public and private programs, an approach that only perpetuates many of these deficiencies. An example is the “family glitch” in which children do not have access to exchange subsidies if the employed parent receives solo coverage through their work. Efforts to patch the various flaws only increase the complexity and administrative burden of our dysfunctional system, and yet patches on a fundamentally flawed infrastructure can never provide the stability that we need.

So what can we do? We can build a new health care financing infrastructure that serves well the needs of not only our children, but all of us. That would be a single payer national health program – an improved Medicare for all – but not just a Medicare that serves only the elderly and persons with disabilities, rather, like Canada, a Medicare that serves all of us. Our children deserve it, and so do we.

Access to Care: Provider Availability in Medicaid Managed Care

Department of Health and Human Services, Office of Inspector General, December 2014

Examining access to care takes on heightened importance as enrollment grows in Medicaid managed care programs. Under the Patient Protection and Affordable Care Act, States can opt to expand Medicaid eligibility, and even States that have not expanded eligibility have seen increases in enrollment. Most States provide some of their Medicaid services—if not all of them—through managed care. The Office of Inspector General received a congressional request to evaluate the adequacy of access to care for enrollees in managed care.

We found that slightly more than half of providers could not offer appointments to enrollees. Notably, 35 percent could not be found at the location listed by the plan, and another 8 percent were at the location but said that they were not participating in the plan. An additional 8 percent were not accepting new patients. Among the providers who offered appointments, the median wait time was 2 weeks. However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months. Finally, primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times.

Findings

• Half of providers could not offer appointments to enrollees
• Forty-three percent of providers were not participating in the plan at the listed location
• Another 8 percent of providers were not accepting new patients
• Among the providers who offered appointments, the median wait time was 2 weeks; however, over a quarter had wait times of more than 1 month
• A small number of providers required patients to submit medical records prior to scheduling an appointment or would not accept patients with certain medical conditions
• Primary care providers were less likely to offer an appointment than specialists; however, specialists tended to have longer wait times
• The median wait time for specialists was twice as long as that for primary care providers

Conclusion

Our findings demonstrate significant vulnerabilities in provider availability, which is a key indicator for access to care. These findings also raise serious questions about the abilities of plans, States, and CMS to ensure that access-to-care standards are met. Without adequate access, enrollees cannot receive the preventive care and treatment necessary to achieve positive health outcomes and improved quality of life.

Notably, 51 percent of providers were either not participating in the plan at the location listed or not accepting new patients enrolled in the plan. When providers listed as participating in a plan cannot offer appointments, it creates a significant obstacle for an enrollee seeking care. Moreover, it suggests that the actual size of provider networks may be considerably smaller than what is presented by Medicaid managed care plans.

Among the providers who offered appointments, the median wait time was 2 weeks. However, over a quarter had wait times of more than 1 month, and 10 percent had wait times longer than 2 months. Long wait times can have a significant impact on patient care. It also raises questions about whether these plans are complying with their States’ standards for access to care, as most States have access standards that require appointments be provided within 1 month or less. That so many providers could not offer appointments within a month raises concerns about enrollees’ ability to obtain timely access to care.

http://oig.hhs.gov/oei/reports/oei-02-13-00670.pdf

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Comment:

By Don McCanne, MD

One of the major features of the Affordable Care Act was to expand Medicaid to cover a greater number of low-income individuals. Although many states opted out of the expansion, nevertheless Medicaid enrollment increased in those states as well. Because of the expansion of state budgets required to cover the burgeoning Medicaid population, most states have moved most if not all of their Medicaid patients into Medicaid managed care plans.

Although states claim that this benefits patients by placing them in organizations that are designed to manage their health care, the real reason is that the states wanted to save money. The managed care plans agree to provide care at a cost lower than the costs of comparable care provided by community hospitals and physicians. Because of the increased enrollment, the total costs of Medicaid are increasing, but the payments per individual are not.

Medicaid, being a welfare program, was already chronically underfunded. Further limiting payments per patient can place a serious strain on resources that would pay for all of the promised care. This OIG study was done in the summer of 2013, before the surge in enrollment that began later that year. If half of providers could not offer appointments to patients at that time, what is happening now that the managed care organizations must accommodate the added demand?

Although there are already many anecdotal reports that the managed care organizations are not meeting their obligations under these state contracts, we will have to wait longer before we have a comprehensive objective evaluation of the extent of the deficiencies in health care services.

Isolating low-income individuals and placing them into an underfunded welfare program will certainly perpetuate disparities in care. Yet the deficiencies in health care services are even worse in those states that opted out of Medicaid expansion, and they are worse for the undocumented residents who are prohibited from participating in Medicaid or in the subsidized plans offered by the exchanges.

Under a single payer national health program – an improved Medicare for all – everyone would have access to a system that met the highest standards of care. The wealthy would still have their high standard of care, but with their special amenities paid for separately, such as private hospital suites, whereas low-income individuals could have the same high standard of care, but without the amenities. Because of the efficiencies of the single payer model, it would not cost the nation any more than we are now spending on health care.

National Trends in the Cost of Employer Health Insurance Coverage, 2003–2013

By Sara R. Collins, David Radley, Cathy Schoen, Sophie Beutel
The Commonwealth Fund, December 9, 2014

Looking at trends in private employer-based health insurance from 2003 to 2013, this issue brief finds that premiums for family coverage increased 73 percent over the past decade—faster than median family income. Employees’ contributions to their premiums climbed by 93 percent over that time frame. At the same time, deductibles more than doubled in both large and small firms. Workers are thus paying more but getting less protective benefits. However, the study also finds that while premiums continued to rise through 2013, the rate of growth slowed between 2010 and 2013, following implementation of the Affordable Care Act. While families experienced slower growth in premium contributions and deductibles over this period, sluggish growth in median family income means families are paying more in premiums and deductibles as a share of their income than ever before.

Premium Increases Outpace Growth in Family Income

Despite the recent slowdown in growth, insurance premiums have risen faster than median incomes for the under-65 population. While average family premiums have climbed by 73 percent since 2003, median family income has risen by 16 percent over the same time period. As a result, total premiums (including the employer and employee shares) relative to income have continued to climb for middle-income working-age families. In 2013, average annual family premiums were 23 percent of median family income, up from 15 percent in 2003 and 21 percent in 2010. There are similar trends in premiums for single coverage: average premiums have climbed 60 percent over the decade, while median income for single-person households has grown by only 11 percent.

Although workers are paying more for their health insurance, their premiums are buying less financial protection, partly because more plans include deductibles and the size of those deductibles has spiked dramatically. In 2013, 81 percent of workers were enrolled in a health plan with a deductible, up from 78 percent in 2010 and just over half (52%) in 2003. As with employee contributions to premiums, incomes have lagged growth in deductibles such that deductibles are consuming an ever-growing share of worker income.

Research has shown that the slower growth in wages during the past decade has been part of a trade-off to preserve health benefits. But while growth in premiums and deductibles has slowed over 2010–2013, median family income, when adjusted for inflation, remains below 2010 levels. Indeed, U.S. families are still trying to recapture lost income from the financial crisis and recession of 2008: real median income is 8 percent lower than it was in 2007. It is unlikely that most families at the middle and lower end of the income distribution are able to detect or feel the premium slowdown in their pocketbooks since they are paying more in premiums and deductibles as a share of their income than ever before.

http://www.commonwealthfund.org/~/media/files/publications/issue-brief/2014/dec/1793_collins_nat_premium_trends_2003_2013.pdf

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Comment:

By Don McCanne, MD

Both premiums for employer-sponsored health plans and employee out-of-pocket expenses for health care have continued to increase well in excess of employee income, in spite of a general slowing in health care spending. Employees “are paying more in premiums and deductibles as a share of their income than ever before,” and it is likely that there is no relief in site, in spite of the enactment of the Affordable Care Act.

We desperately need public policies to correct the excessive and increasing inequality in America, and a good start would be to replace our current inequitable health care financing system with an equitably-financed and more efficient single payer national health program – an improved Medicare that covers everyone.

The Health-Cost Slowdown Isn’t Just About the Economy

By David Leonhardt
The New York Times, December 5, 2014

It’s one of the most important economic questions today: Is the snail-like growth of health costs over the last several years a real trend, or is it merely a temporary part of the Great Recession’s aftermath?

The data experts who compile the government’s official numbers on health spending lean toward the more pessimistic view. They think the slowdown – to the lowest level of growth on record – stems in large part from Americans skimping on medical care during tough times.

In the aftermath of the 1990-91 recession and the slow recovery that followed, health spending stopped growing more quickly than the rest of the economy. It accounted for 13.4 percent of economic output in 1996, the same share as it had in 1993.

But the weak economy doesn’t seem to have been the main reason. The rise of health maintenance organizations (or H.M.O.’s) – along with other attempts by insurers to hold down costs – was.

Then a backlash against H.M.O.’s took hold, and health spending started growing rapidly again. The surge didn’t end until the last few years, when the efforts of the reformers began to have a widespread effect.

It’s simply not true that G.D.P. and health costs have historically moved in tandem. On the other hand, the experience of the 1990s demonstrates that a slowdown in health costs isn’t guaranteed to persist.

If patients start to rebel against some of the changes that have held down health costs – like narrow networks, which restrict which doctors they can see – spending may start to rise again. It also may start to rise if labor unions manage to undercut a tax on generous health plans or if Republicans succeed in stopping efforts to make Medicare more efficient. (Yes, that’s related to the infamous death-panel debate.)

The American health care system really is changing. What happens next will be one of the biggest economic stories of the coming decade.

Comment:

By Don McCanne, MD 

There are several factors contributing to the slowdown in health care spending, but one of the most important is insurance innovation that is impairing affordability and access. These innovations include “consumer empowerment” measures, such as ever-higher deductibles, shift from co-payments to higher coinsurance, establishment of higher-cost tiers, and narrower provider networks that impair access.

The supporters of consumer-directed health care celebrate these “savings” that we are seeing, but this represents forgone health care – much of it beneficial health care. While some cite studies such as the RAND HIE and the Oregon natural experiment as showing no harm done, in fact, these studies were not powered to shown harm, but only to show a difference in spending.

People are doing without the care that they should have. Based on my clinical experiences, people really do suffer and die merely because they delayed care when they could not afford it.

Today, because of the transfer of health care costs to patients, being insured is no longer enough to prevent personal bankruptcy. It is not even enough to ensure that you will not die from causes for which intervention is effective.

There are far more effective ways to control health care spending, beginning with a single payer system. The recovered administrative waste alone would be more than enough to pay for care that patients are now avoiding due to our ill-advised and inhumane “skin in the game” policies.