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Robert Wood Johnson Foundation, October 4, 2018

The threat to consumers posed by bills from out-of-network (OON) health care providers is an issue that has been gaining prominence lately, with coverage from the media and growing policymaker interest.

With the growing use of managed care plan designs and narrow networks, OON coverage is becoming increasingly rare. This tendency is more pronounced in the fully insured market. In the individual market in particular, there has been a steep decline in the percent of plans that offer OON coverage, from 58 percent in 2015 to 29 percent in 2018. The decline in the small group market has been far less sharp, and probably tracks more closely to what is happening in larger employer plans. Part of the difference in the two segments reflects patterns in carrier participation in the individual market. National commercial carriers, which are more likely to offer broader network plans, exited the individual market in droves in 2016 and 2017, leaving a market that is dominated by Blues and Medicaid-managed care organizations (MMCO). MMCO plans almost always offer closed-network plans, and even many Blues plans have shifted to narrow network offerings in the individual market.

High Deductibles

The share of plans with OON benefits has declined, and so has the comprehensiveness of those OON benefits that are offered. In about 95 percent of individual and small group plans with OON benefits, the deductible must be met before there is any cost-sharing. OON deductibles are generally high, particularly in the individual market, where the median OON deductible is approximately $12,000. In about 30 percent of individual market plans with OON coverage, the deductible is greater than $20,000. The small group market is quite different, with a median deductible of about $6,000 and virtually no deductibles higher than $20,000.

Infinite Maximum Out-of-Pocket

After the deductible is met, cost-sharing usually takes the form of 50 percent co-insurance. This generally continues until the maximum out-of-pocket (MOOP) limit is reached. For ACA plans, the MOOP for in-network coverage is capped at $7,350 for individuals, and at about $14,700 for families. Yet for OON benefits, there is no such limit. In fact, about one-third of individual marketplace plans have no dollar amount for the MOOP, meaning that cost-sharing can continue basically forever once the deductible is reached. For plans that do have dollar limits, they are high. The median for the individual market is close to $19,000. In the small group markets this is much less common, as only 8 percent of plans with OON benefits have no MOOP limit. Median out-of-pocket maximums for plans with dollar limits are about $15,000 in the small group market. 

OON bills are a source of concern to consumers, and a recent study showed that approximately 20 percent of hospital visits among patients with large group coverage resulted in an OON bill. In the case of medical emergencies, the ACA requires that OON care is reimbursed at in-network rates, although depending on state law, providers may still “balance bill” patients. Consumers with plans in the individual and small group markets have a high level of exposure to these charges. Narrow networks increase the likelihood that providers are out of network. Many plans in the small group market and most plans in the individual market do not have any OON coverage at all, and for those that do, the coverage tends to be very minimal, leaving consumers with a lot to lose in the event of an unpleasant surprise.

https://www.rwjf.org…

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Comment:

By Don McCanne, M.D.

One of the most important reasons for enactment of the Affordable Care Act was the inadequacy of plans offered in the individual insurance market. Though some of the deficiencies were corrected, such as ensuring availability of coverage for individuals with pre-existing medical conditions, it is not the nature of the insurance industry to forgo opportunities to improve the business model of their insurance products. This report on what has happened in the individual insurance market since the implementation of ACA should raise alarms.

With an emphasis on controlling access to care by establishing narrower networks of health care providers, the insurers have reduced coverage provided for care obtained outside of the networks. As recently as 2015, 58 percent of individual plans offered coverage for care obtained outside of networks. This year that has declined to only 29 percent. If there is out-of-network coverage the average deductible is about $12,000 and for about 30 percent of the plans it is over $20,000. Since out-of-network care is often unavoidable, the potential financial exposure can be very great in spite of the effort of some states to regulate such exposure.

The Affordable Care Act did place limits on the maximum out-of-pocket costs to which enrollees in exchange plans would be exposed, but this maximum may not apply to care obtained out-of-network. Some individual plans do have a maximum on out-of-network out-of-pocket costs though the average maximum is about $19,000. The majority of individual plans do not have an out-of-pocket maximum and thus cost sharing can continue forever. Thus this coverage would be inadequate for a majority of individuals who had to obtain a significant portion of their care out-of-network.

It is not in the nature of the private insurers to find ways to remove financial barriers to care for patients. Quite the opposite. To meet their own business goals, they increase barriers. After the implementation of ACA we have seen an increase in the use of narrow networks and higher deductibles. If we find ways to reduce the negative impact of these policies on patients, the insurance industry, as masters of innovation, will find more ways to avoid paying for health care. In a way it is our fault because we have allowed our elected representatives to keep these people in charge.

Suppose we had a well designed, single payer national health program – an improved Medicare that covered everyone. Networks designed to limit access would not exist. High deductibles designed to erect financial barriers to care would not exist. Unlimited out-of-pocket spending would not be a problem since costs for essential health care services would be fully covered. Public programs are designed to serve patients whereas private programs are designed to serve business interests.

Again, insurer innovation since full implementation of ACA has been detrimental, as this report shows, and further detrimental innovation is inevitable as long as we leave the private insurance industry in charge. Instead of continuing with our relatively feeble efforts to try to level the playing field, let’s establish our own level field supervised by our own public stewards.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Donald J. Trump
USA Today, October 10 2018

Excerpts

Throughout the year, we have seen Democrats across the country uniting around a new legislative proposal that would end Medicare as we know it and take away benefits that seniors have paid for their entire lives.

Dishonestly called “Medicare for All,” the Democratic proposal would establish a government-run, single-payer health care system that eliminates all private and employer-based health care plans and would cost an astonishing $32.6 trillion during its first 10 years.

As a candidate, I promised that we would protect coverage for patients with pre-existing conditions and create new health care insurance options that would lower premiums. I have kept that promise, and we are now seeing health insurance premiums coming down.

I also made a solemn promise to our great seniors to protect Medicare. That is why I am fighting so hard against the Democrats’ plan that would eviscerate Medicare. Democrats would gut Medicare with their planned government takeover of American health care.

The Democrats’ plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised. By eliminating Medicare as a program for seniors, and outlawing the ability of Americans to enroll in private and employer-based plans, the Democratic plan would inevitably lead to the massive rationing of health care. Doctors and hospitals would be put out of business. Seniors would lose access to their favorite doctors. There would be long wait lines for appointments and procedures. Previously covered care would effectively be denied.

In practice, the Democratic Party’s so-called Medicare for All would really be Medicare for None. Under the Democrats’ plan, today’s Medicare would be forced to die.

The Democrats’ plan also would mean the end of choice for seniors over their own health care decisions. Instead, Democrats would give total power and control over seniors’ health care decisions to the bureaucrats in Washington, D.C.

The first thing the Democratic plan will do to end choice for seniors is eliminate Medicare Advantage plans for about 20 million seniors as well as eliminate other private health plans that seniors currently use to supplement their Medicare coverage.

Next, the Democrats would eliminate every American’s private and employer-based health plan. It is right there in their proposed legislation: Democrats outlaw private health plans that offer the same benefits as the government plan.

Republicans believe that a Medicare program that was created for seniors and paid for by seniors their entire lives should always be protected and preserved. I am committed to resolutely defending Medicare and Social Security from the radical socialist plans of the Democrats.

Donald J. Trump is the president of the United States.

https://www.usatoday.com…

***

Comment:

By Don McCanne, M.D.

The good news about this op-ed by President Donald Trump is that the Medicare for All concept has gained so much public support that the president feels that he must attack it in his own inimitable style, that is by being untruthful about it in an effort to reduce the political traction that it has been gaining. Although his misstatements and falsehoods are so obvious that we should not have to refute them, nevertheless it is very difficult to remain silent over his outrageous claims. Can’t help but be compelled to respond to at least a few of them.

— “a new legislative proposal that would end Medicare as we know it and take away benefits that seniors have paid for their entire lives”

Improving Medicare and expanding it to cover everyone does not end Medicare and it does not take away benefits from seniors. It expands benefits for seniors, and everyone else.

— “Dishonestly called ‘Medicare for All'”

It might be dishonest to merely add a public option to our fragmented, dysfunctional health care financing system and call that “Medicare for All,” but that is not what the president is talking about. When the proposal would expand Medicare to cover everyone, just what is dishonest about calling that Medicare for All?

— “I promised that we would protect coverage for patients with pre-existing conditions”

The Trump administration is supporting the lawsuit by Republican state attorneys general that asks for repeal of the entire Affordable Care Act which would repeal the requirement that insurers cover pre-existing conditions. How is that keeping his promise?

— “I promised that we would…create new health care insurance options that would lower premiums”

The new products, such as association health plans, have lower premiums only because they do not provide adequate coverage. People who believed they were insured will be very disappointed when they find they will have to file for medical bankruptcy anyway, in spite of their insurance.

— “we are now seeing health insurance premiums coming down”

Trump’s effort to sabotage the Affordable Care Act by cancelling subsidies caused insurers to sharply increase their premiums. When the subsidies were reestablished, some of the insurers were able to reduce their premiums. There was no Trump magic that brought the premiums back down.

— “I also made a solemn promise to our great seniors to protect Medicare”

The Republicans have repeatedly expressed their desire to implement premium support which is a scheme to privatize Medicare. Giving priority to private investors over patients is not protecting Medicare.

— “That is why I am fighting so hard against the Democrats’ plan that would eviscerate Medicare”

Expanding Medicare benefits can hardly be called an evisceration.

— “Democrats would gut Medicare with their planned government takeover of American health care”

Under Medicare for All, health care delivery remains as it is now – mostly in the private sector – and health care decisions are made by patients in consultation with their health care professionals. That is not a government takeover of health care.

— “The Democrats’ plan means that after a life of hard work and sacrifice, seniors would no longer be able to depend on the benefits they were promised”

Seniors absolutely would be able to depend on the benefits they were promised, and even more.

— “the Democratic plan would inevitably lead to the massive rationing of health care”

With the amount we are spending on health care, we have more than enough funds to ensure adequate capacity in the system.

— “Seniors would lose access to their favorite doctors”

Private insurers limit patient access to provider networks, whereas patients would have free choice of their health care professionals under Medicare for All.

— “There would be long wait lines for appointments and procedures”

Several nations have shown that resource planning and queue management can prevent excessive queues in the system.

— “Previously covered care would effectively be denied”

Who is going to deny care? Donald Trump?

— “the Democratic Party’s so-called Medicare for All would really be Medicare for None”

What an outrageous statement.

— “The Democrats’ plan also would mean the end of choice for seniors over their own health care decisions”

What a lie! (There, I said it.)

— “Democrats would give total power and control over seniors’ health care decisions to the bureaucrats in Washington, D.C.”

As mentioned before, health care decisions are the patients’ own, made in consultation with their health care professionals.

— “eliminate Medicare Advantage plans for about 20 million seniors as well as eliminate other private health plans that seniors currently use to supplement their Medicare coverage”

Medicare Advantage and Medigap plans waste funds through their administrative excesses. It would be of greater value to roll any extra benefits of those plans into an improved version of the more efficient traditional Medicare program.

— “the Democrats would eliminate every American’s private and employer-based health plan”

Finally! Thank goodness.

— “I am committed to resolutely defending Medicare and Social Security from the radical socialist plans of the Democrats”

What? Defending the social insurance programs of Medicare and Social Security from the people who created and support them? Besides, now that the Republicans have cut taxes for the rich they say that we need to cut our entitlement spending – Social Security and Medicare.

Lies and distortions. And when they are repeated at Trump’s perpetual rallies, his forever loyal followers passionately cheer him on with total disregard for absence of a factual basis for his pronouncements. As a child, I remember newsreels of what seemed to me to be similar rallies held in a land far, far away. That did not turn out well. I have often wondered what caused the crowds to show such support. I still do.

Physicians for a National Health Program (PNHP) is a single issue advocacy organization supporting a single payer national health program – an improved Medicare for All. PNHP does not support any political candidates nor political parties. If there is a misperception of a political overtone in this article, it reflects strictly the ineptitude of the author in his effort to comply with 501(c)(3) status.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By John O’Shea
Health Affairs Blog, October 3, 2018

Although still a subject of debate, the fee-for-service health care payment system that reimburses providers for individual services is widely indicted for promoting care that is inefficient, uncoordinated, and too often fails to meet the needs of patients. Whether or not fee-for-service is the main culprit, the escalating cost and inconsistent quality of US health care highlights the need for a better system. In discussions about what that system should look like, the terms “patient-centered” and “value-based” have become buzz words for payment and delivery reform in health care.

Unfortunately, many well-intentioned efforts to move to a more effective system are adding to the already substantial administrative and regulatory burden on physicians, hospitals, and other providers. In turn, these cumbersome new initiatives stifle innovation and obstruct meaningful payment and delivery reform. The current administration has appropriately recognized that this over-regulation is impeding the transition to a truly patient-centered and value-based health care system. Recently announced initiatives such as “Meaningful Measures” and “Patients over Paperwork” are promising because they aim to reduce the amount of time physicians spend on record-keeping and administrative tasks, allowing them to re-focus on patient care. However, the administration’s recent refusal to consider new payment and delivery models recommended by the Physician-Focused Payment Model Technical Advisory Committee (PTAC) throws into question whether the Department of Health and Human Services (HHS) is serious about removing barriers to innovation.

The Impact Of MACRA

In 2015, the Medicare Access and CHIP Reauthorization Act (MACRA) became law. In addition to repealing the flawed Sustainable Growth Rate (SGR) payment system and providing a period of payment stability, MACRA seeks to stimulate the transition to a value-based health care system through payment incentives embodied in the Quality Payment Program (QPP). The QPP provides for two payment approaches for physicians and other providers in Medicare: the Merit-based Incentive Payment System (MIPS) and alternative payment models (APMs). While the goals underlying MACRA are sound, the original framework evolved into an overly complex statute, leading to an equally complex set of rules governing implementation, all of which undermine MACRA’s original intent.

The Burden Of MIPS

MIPS links payment to an individual provider’s performance on measures in four categories: quality, advancing care information, clinical practice improvement activities, and resource use. Once MACRA is fully implemented, an individual provider’s performance will be compared to the average performance of all MIPS-eligible providers in the previous year, and the provider will receive a positive, negative, or neutral update to their fee schedule payments two years later.

The Medicare Payment Advisory Commission (MedPAC) has stated that the current iteration of MIPS “is unlikely to clearly identify high-value or low-value clinicians and hence may be of limited utility for beneficiaries (in selecting high-value clinicians), for clinicians themselves (in understanding their performance and what to do to improve), or for the Medicare program (in adjusting payments based on value).” MedPAC recently recommended scrapping MIPS entirely and replacing it with a voluntary program.

The program needs no less than a major overhaul. It is increasingly clear that equitably measuring the performance of individual providers from different specialties, practice settings, and geographic regions on a national scale is not only unrealistic, it is inconsistent with many of the basic tenets of payment and delivery reform, such as team-based care, coordination of services, and the aggregation of payments to incentivize these principles.

APMs, The PTAC, And Barriers To Innovation

The underlying goal of the QPP is to incentivize providers to transition out of fee-for-service and into APMs. However, current Advanced APM options are limited to Centers for Medicare and Medicaid Services (CMS)-approved initiatives. These initiatives have excessively stringent requirements, which have contributed to disappointing early results and exits of a number of early adopters.

MACRA established the PTAC as a forum for practicing physicians to develop innovative ideas about Medicare payment and delivery reform. However, even though the current committee members comprise a veritable “dream team” of dedicated payment and delivery reform experts, the complex regulations governing the application process and CMS’s rules about testing and implementing recommended models prevent the committee from realizing its original intent.

Given the excessive regulatory requirements and resultant sluggish start of the CMS-sanctioned initiatives, combined with the restrictions placed on the PTAC process, MACRA (as currently structured) is unlikely to realize its potential as a catalyst for transitioning to patient-centered, value-based health care.

Recently HHS released its response to comments and recommendations from the PTAC regarding 12 models submitted to the HHS secretary between October 2017 and May 2018. Citing HHS criteria for evaluating proposed models, the secretary declined to consider any of the models for implementation or further testing, listing several considerations that the agency used to support this decision.

Looking Ahead

Transitioning to a patient-centered and value-based health care payment and delivery system is a good idea. However, initiatives that divert physician time away from clinical care are not patient-centered, and investing precious resources on administrative and reporting requirements without any improvement in the quality of care is anything but value-based. The administration has promised to address the excessive regulations that have so far hindered meaningful payment and delivery reform. Now, the administration and Congress need to follow through on that promise. Otherwise, the terms “patient-centered” and “value-based” will remain largely hollow buzz words.

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Published Comment:

By Don McCanne, M.D.

Fixation on the concept of value-based health care has led the policy community to craft reform models that inherently increase the administrative inefficiencies in our health care financing system – an approach which bears some of the blame for the oppressive regulatory oversight. MACRA, MIPS, APMs, and, by extension, ACOs thus far have done very little to control costs (especially when including provider compliance costs). In spite of the relatively advanced state of health policy science, it is no wonder that none of the proposals submitted through the Physician-Focused Payment Model Technical Advisory Committee (PTAC) were considered worthy of experimentation since they were developed within the constraints of legislation and regulation defining ACOs and the other alternative payment models.

Rather than blaming excessive regulation, we should ask whether it is the right kind of regulation. Over half a century ago, Kenneth Arrow showed us that deregulating the private health care market was not the answer. Since then, many other industrialized nations, in fact all of them, have shown us that the rate of health care cost increases can be slowed to a sustainable level while providing essentially everyone with comprehensive health care coverage. In all of these nations regulatory oversight has been an essential element, but the right kind of regulation.

In the United States it is looking like a well designed, single payer model – an improved version of Medicare – would be most suited to our politics and culture. The latest polls show that close to one-half of Republicans have now joined a majority of Democrats and Independents in supporting Medicare for all. Though MACRA is another misstep on the way there, we should get past that and move forward with high value, patient-centered care that is affordable for everyone and protected with just the right dose of regulatory oversight through a publicly-financed and publicly-administered system. In such a system patient-centric care, value, and regulation are quite compatible.

https://www.healthaffairs.org…

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The Secretary of Health and Human Services

June 13, 2018

I am very pleased to respond to the comments and recommendations of the Physician-Focused Payment Model Technical Advisory Committee (PTAC) transmitted between October 2017 and May 2018. Shifting our health care system to one that pays for value rather than volume is one of my top four priorities as Secretary of Health and Human Services (HHS). PTAC can help us make that shift by reviewing promising new ideas, providing expert analysis, commentary, and recommendations, and working collaboratively to realize the promise of new physician-focused payment models (PFPMs).

Considerations for Proposed Model Submissions

Prior to PTAC beginning its work, HHS and CMS set forth 10 criteria for PTAC to use in evaluating proposed PFPMs (as required by the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA)). Consistent with these criteria and factors, I also ask that stakeholders take into account the following considerations as they develop new proposed payment models. This information, as well as the 10 established criteria for PFPMs and CMS’ model selection factors, have informed my review of responses to the comments and recommendations transmitted by PTAC on 12 proposed PFPMs.

1. HHS seeks models that demonstrate potential for significant impact on the Medicare population in ways where we can conduct a robust evaluation. PTAC has recommended several proposed models for limited-scale testing. In its Proposal Submission Instructions, PTAC indicates that the limited-scale testing “category may be used when the PTAC determines a proposal meets all or most of the Secretary’s criteria but lacks sufficient data to (1) estimate potential costs, savings or other impacts of the payment model and/or (2) specify key parameters in the payment model (such as risk adjustment or stratification), and the PTAC believes the only effective way to obtain those data would be through implementation of the payment model in a limited number of settings.” To the extent the limited-scale recommendation for a proposed model test precludes robust evaluation, we would be unlikely to implement such a recommendation.

2. Use of proprietary tools or tools that are not already developed in a proposed APM is an obstacle to HHS’ testing of the model. In prior Secretarial responses, HHS has communicated concerns about proposed models that require the use of specific proprietary products. HHS cannot endorse, promote or rely on a unique product.

3. Providing care in accord with current standards of practice or accelerating adoption of emerging standards of care do not require an APM. Although APMs often reward the provision of higher quality care, care that is provided would always meet current standards of care, regardless of the way in which a practitioner is paid. CMS would not implement a model that pays physicians solely for implementing standard practice and following established guidelines for care.

In summary, I look forward to reviewing proposals that present ideas that go beyond the scope of our current model portfolio, bringing in fresh and bold ideas for PFPMs from the field.

Sincerely,

Alex M. Azar II

The appendix includes 12 PFPM proposals and the reasons why each one was rejected:
https://aspe.hhs.gov…

***

Comment:

By Don McCanne, M.D.

Please note my comment above that was published on the Health Affairs Blog website.

The letter by HHS Secretary Alex Azar is important because it demonstrates the fallacy that  we can somehow create a new health car financing system that pays for value rather than volume. The process set up by MACRA establishes the Physician-Focused Payment Model Technical Advisory Committee (PTAC) which evaluates new designs for alternative payment models (APMs), as if a new model that converts volume to value could be created. Yet all proposals submitted to HHS were rejected. Pretending that someone, somewhere, sometime will think up a new way to do that is an escape to fantasyland. MACRA, MIPS, and APMs are a failure and need to be dumped.

The goal of reducing volume is to control spending. Models designed specifically to do that either reduce beneficial health care services – an undesirable outcome – or they fail to have a significant impact on costs, as the disappointing results with ACOs demonstrate. On the other hand, the economic tools used in a model that already exists – a well designed single payer system (reduction of administrative excesses, global budgeting, negotiated rates, bulk purchasing, etc.) – do slow spending (value) without eliminating beneficial services (volume). So you can have greater value while maintaining an appropriate volume of services.

We could use the current process and submit to PTAC the PNHP single payer Medicare for all model, but HHS Secretary Azar and CMS Administrator Verma have already said they would reject Medicare for all.

This just demonstrates once again that we must intensify our efforts in educating the public so that we reach a threshold where the people lead and the politicians have no choice but to follow.

As FDR said, “The ultimate rulers of our democracy are not a President and senators and congressmen and government officials, but the voters of this country,” and, in another context, “now make me do it.”

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Shannon Firth
MedPage Today, October 5, 2018

“Risk” and “predictability” were key themes in the discussion between accountable care organization (ACO) participants and Adam Boehler, the recently appointed director of the Center for Medicare and Medicaid Innovation (CMMI).

“There are a lot of folks that should take risk and there are a lot of folks that shouldn’t take risk,” Boehler said Thursday at the National Association of ACOs (NAACOS) conference here. “And I’m a big believer in being what you are.”

One group that probably shouldn’t take risk: single physician groups. “That’s silly,” he said. But for those providers and hospitals who are ready, it’s his responsibility and that of the Centers for Medicare & Medicaid Services (CMS) to create “practical and simple” policies to help participants succeed, Boehler said.

And for those who aren’t? “It’s also our job to say to folks, ‘If you’re not cutting it, get out of the way,’ because there are others that will come that will cut it … People will come in and take that risk and do something with it,” he said.

Boehler’s comments are in line with CMS’s more aggressive vision for ACOs to move towards risk.

Training Wheels Off

In August, CMS released a proposed rule for the Medicare Shared Savings ACO program which shortened the glide path for ACOs to stay in upside only models (those without any risk) for 2 years, down from an initial 6 years.

NAACOS president and CEO Clif Gaus, ScD, swiftly panned the idea of a shorter transition period, saying at the time that CMS was “pulling the rug” out from under the program.

In May, a NAACOS survey found that 71% of ACO participants would likely leave the Medicare Shared Savings Program (MSSP) rather than take on two-sided risk.

https://www.medpagetoday.com…

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NAACOS: Proposed rule changes to ACO program are ‘deal breakers’

By Tina Reed
Fierce Healthcare, October 5, 2018

Proposed changes to the federal accountable care organization (ACO) model—namely, a cut in the shared savings rate from 50% to 25%—would cut the knees out from under the program, board members of the National Association of ACOs said on Thursday.

Speaking with reporters at their annual conference in Washington, D.C., ACO leaders said they supported many of the proposed changes that the Centers for Medicare & Medicaid Services have brought forward regarding ACOs.

But proposed rules that would speed their path to risk and reduce the reward they would reap in return for any savings they realize are “deal breakers” for new entrants to the program, said Clif Gaus, NAACOS president and CEO.

“I don’t know any ACO that would roll the dice for 25%,” Gaus said. “You’ve got the carrot and the stick. And you just cut the carrot in half.” 

https://www.fiercehealthcare.com…

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Verma, Azar take aim at ‘Medicare for All’ proposals

By Paige Minemyer
Fierce Healthcare, October 5, 2018

Centers for Medicare & Medicaid Services (CMS) Administrator Seema Verma took another swipe at calls for a “Medicare for All” healthcare system this week, saying expanding those benefits to every American would “dilute” the program.

“Putting more people in the program is not going to solve the problem, and actually threatens the focus and security of the program for seniors,” Verma said.

When FierceHealthcare requested more details on how expanded enrollment would hurt seniors, CMS declined to provide specific data.

Department of Health and Human Services Secretary Alex Azar has also drawn a clear line in the sand on Medicare for All. In a speech last week, hosted by the Nashville Healthcare Council, Azar said that expanding the program to all Americans would eliminate their ability to make health choices for themselves.

“It’s simple math: Higher payments from commercial insurers help doctors take on seniors whose Medicare plans pay less,” Azar said. “It’s far from an ideal set-up, but a single government system would completely unravel it, without a theory for how seniors’ access would be protected.”

https://www.fiercehealthcare.com…

***

Comment:

By Don McCanne, M.D.

At last week’s meeting of the National Association of ACOs (NAACOS) there was considerable interest in CMS’s proposed rule in which accountable care organizations (ACOs) would be forced into downside risk after only two years instead of the previous six allowed, and the share of any savings for the ACO would be reduced from 50 percent to 25 percent, with Medicare keeping 75 percent.

Of course no ACO wants downside risk but that is their stick that drives accountability for costs of health care. If forced into downside risk, the ACOs want time to adjust their operations to meet the required benchmarks, but that time would be cut short by the rule such that most ACOs would anticipate losses. The carrot for sharing in savings also is being reduced in half. An industry survey suggests that close to three-fourths of ACOs would leave the program rather than take on two-sided risk, and you can imagine that there will be a paucity of new entrants into the program, if any at all.

Although the rule is still only proposed, it is well on its way to being adopted since it has the strong support of CMS administrator Seema Verma and HHS Secretary Alex Azar. They are so determined that CMS’s Adam Boehler, director of the Center for Medicare and Medicaid Innovation (CMMI), says, “If you’re not cutting it, get out of the way.”

Oops, where did everyone go?

ACOs have fallen far short of expectations, and now they want to tighten the vise on providers. How could anyone with the least knowledge of health policy ever conceive that this model could succeed? If you consider the provider costs of participating in the program, it has already failed.

As regular readers know there is a proven model that would work for all of us, patients and providers alike – a well designed, single payer, improved Medicare for all. Yet last week both Verma and Azar again have attacked Medicare for all. Can we change their minds, or do we need to replace them?

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Sarah Kliff
Vox, October 4, 2018

Leon Lederman won a Nobel Prize in 1988 for his pioneering physics research.

But in 2015, the physicist, who passed away Wednesday, sold his Nobel Prize medal for $765,000 to pay his mounting medical bills. The University of Chicago professor began to suffer from memory loss in 2011, and died in an Idaho nursing home.

In a lot of ways Lederman’s story represents the best and worst of America. Lederman was born in the 1920s to a father who worked in a laundry facility. He went on to discover the Higgs boson subatomic particle, the so-called “God particle.”

But even an accomplished physicist and university professor isn’t immune from America’s sky-high health care prices.

https://www.vox.com…

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Leon Lederman, 96, Explorer (and Explainer) of the Subatomic World, Dies

By George Johnson
The New York Times, October 3, 2018

Leon Lederman, whose ingenious experiments with particle accelerators deepened science’s understanding of the subatomic world, died early Wednesday in Rexburg, Idaho. He was 96.

Early in his career Dr. Lederman and two colleagues demonstrated that there are at least two kinds of particles called neutrinos (there are now known to be three), a discovery that was honored in 1988 with a Nobel Prize in Physics. He went on to lead a team at the Fermi laboratory, in Batavia, Ill., that found the bottom quark, another fundamental constituent of matter.

He and his wife, Ellen, moved to their place in Idaho, in Driggs, just before his 90th birthday. Found to have dementia, he was advised by his doctors to live in peaceful surroundings. In 2015 the couple agreed to let an online auction company sell his Nobel Prize medal. The proceeds, $765,002 before taxes, were set aside for future medical expenses.

“There’s always a place at the edge of our knowledge, where what’s beyond is unimaginable, and that edge, of course, moves,” Dr. Lederman told The Times in 1998.

In the beginning were the laws of physics. But where did the laws come from? At that point, he said, “You’re stuck.”

“I usually say, ‘Go across the street to the theology school, and ask those guys, because I don’t know.’”

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

Yes, only in America. Nobel laureate Leon Lederman sold his Nobel medal in order to help pay for his pending medical bills.

To learn more about this remarkable gentleman, the full New York Times obituary is well worth reading.

Then take time out for a contemplative interlude. We all know about the injustices of our health care financing system that negatively impact those of modest or meager means, but a Nobel laureate?

We can do better that that, to the benefit of everyone.

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Medical Group Management Association, October 2018

The federal government has focused on decreasing the regulatory burden on medical group practices. MGMA has long been a champion for decreased regulatory burden and increased administrative simplification and standardization in order to achieve a more efficient and effective care delivery process for patients and providers.

This study is the second in a series to assess the burden level of regulatory processes for physician practices participating in Medicare programs.

The move toward value

How do you view the move to paying physicians based on value of care delivered rather than volume of services provided?

57% – Negative
38% – Positive
5% – No opinion

Has the move toward value-based payment (in Medicare/Medicaid) improved the quality of care for your patients?

76% – No
15% – Yes
9% – No opinion

Has the move toward value-base payment (in Medicare/Medicaid) increased the regulatory burden on your practice?

90% – Yes
6% – No
4% – No opinion

Overall, has the move toward paying physicians based on value been successful to date?

79% – No
8% – Yes
13% – No opinion

https://www.mgma.com…

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The Future of Healthcare: A National Survey of Physicians

The Doctors Company

The 2018 Future of Healthcare report, compiled from the observations of more than 3,400 doctors, has uncovered a complex picture of the attitudes of physicians nationwide toward the important issues facing the industry.

43% of Doctors Believe Value-Based Care Will Negatively Impact Physician-Patient Relationship (42% No impact; 15% Positive impact)

61% of Doctors Believe Value-Based Care Will Negatively Impact Their Practice

https://www.thedoctors.com/future

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Half A Decade In, Medicare Accountable Care Organizations Are Generating Net Savings

By William Bleser, David Muhlestein, Robert Saunders, Mark McClellan
Health Affairs Blog, September 21, 2018

Summing Up

The MSSP (Medicare Shared Savings Program) like overall health care reform remains work in progress, with performance trends continuing to show improvement. While some organizations have been participating for half of a decade, most MSSP participants are still just a few years into their care transformation journey. Quality scores are generally high, the program is achieving net savings, and cost reduction is improving. But the modest savings suggest that learning from MSSP experiences to date to modify it for the future – and reinforcing these changes with other accountable care reforms – could do more to bend the curve of future cost growth. The new MSSP proposed rule would shift many more ACOs toward downside risk. But if many organizations that could have achieved savings over time drop out, and if those payments represent a small minority of total payments, even heightened downside risk may be insufficient to drive more substantial change toward a value-based health care. We are still early in the journey, but with more experience and more participants, the opportunities for evidence-based payment reforms and for shared learning to accelerate progress are greater than ever.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The future of health care financing is all about value-based care (VBC) – paying based on value rather than volume – or so you would believe based on the proclamations of politicians and the policy community and the dissemination of that concept through the academic literature and lay media.

We are already several years into the Medicare Shared Savings Program (MSSP) through VBC experimentation using accountable care organizations (ACOs) and other alternative payment models (APMs). Two important questions to ask now about VBC are 1) How is it doing so far, and 2) What do the physicians on the front line think about it?

There are thousands of articles on VBC, but the status to date could be summed up by the recent Health Affairs Blog by Mark McClellan and his colleagues. They state that quality scores are generally high, but they are relatively meaningless since they have been pared back to measuring small bits of minutiae that are easy to game. They state that the program is achieving modest savings, but that is only in Medicare spending and it is almost negligible. When including the provider costs of complying with the program (hardware and labor) which are not included in the estimates, VBC through ACOs in the MSSP (in the language of the policy community) is resulting in higher total costs – the exact opposite of what VBC is supposed to deliver. As with so many of the academic papers on the topic, McClellan and colleagues state, “We are still early in the journey, but with more experience and more participants…” Come on.

The experiment with VBC has failed, though many are not ready to admit it. But the concept of value-based care now has a life of its own. Of great concern is that members of Congress who support Medicare for All are moving forward with changing HR 676 – The Expanded and Improved Medicare for All Act –  modifying it to include supposedly modern concepts of value-based care. But when you ask them to define specifically what value-based care is, they may reply with the meme that we will no longer pay for volume (which is untrue since even the most basic care requires a certain volume that must be funded). When you ask them to clarify what that means as far as it relates to transformation of the health care delivery system, after stumbling around, they may come up with accountable care organizations. Ask them what that is and the better informed politicians might tell you that it is an organization that is accountable for quality and costs (how astute of them). Zero in on that and ask them to define precisely what that is structurally, beginning with it being an organization to which patients are assigned without their knowledge. Got them, because  they don’t know what an ACO is because a precise definition does not even exist (even though ACOs were also included in the Affordable Care Act). And yet the progressives want to change HR 676 to include VBC and ACOs within the legislation.

They don’t seem to be listening to the people on the front line – the physicians who are providing so-called value-based care, often through ACOs. What do the physicians have to say?

* 79% do not believe that value-based care has been successful to date

* 90% state that value-based care has increased the regulatory burden on them

* 76% do not believe that value-based care has improved the quality of care

* 61% believe that value-based care negatively impacts their practices

The process of rewriting HR 676 has already begun. The politicians involved seem to think that they are improving this two-decades-old legislation by introducing modern concepts of value-based care. The concept may be an empty meme, but the application of the concept is already causing serious harm where it really counts – at the physician-patient interface. When we are aiming for patient care nirvana through a single payer, improved Medicare for all, we don’t want to damage or destroy it by injecting into it a major element of VBC hell. Let the politicians know.

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By Patricia S. Keenan, Paul D. Jacobs, and G. Edward Miller
Health Affairs, October 2018

Abstract

Obtaining health insurance coverage has historically been challenging for workers at small firms and the self-employed. Using data from the Medical Expenditure Panel Survey, we found that the overall uninsurance rate for these workers and their families declined by 5 percentage points over the past decade, but one-third of those with lower incomes remained uninsured in 2014–15.

From the Introduction

Obtaining health insurance has been a long-standing challenge for many self-employed and small-firm workers. The nature of this challenge has evolved over the past decade, as the Great Recession reduced access to employer-sponsored insurance, and health insurance reforms under the Affordable Care Act (ACA) increased the availability of private and public coverage. While the decline in employer coverage offer rates in small firms is well established, less is known about how recent changes to that coverage, individual insurance, and Medicaid have affected how small-firm and self-employed workers and their families get coverage.

Using data from the Medical Expenditure Panel Survey–Household Component (MEPS-HC), we found that insurance coverage improved at all income levels over the ten-year period from 2004–05 to 2014–15 (we pooled data into two-year pairs to improve precision). Those with family incomes below 200 percent of the federal poverty level showed the largest gains (9.5 percentage points), but one-third remained uninsured in 2014–15.

These trends are particularly important given ongoing policy interest in improving coverage for small-firm and self-employed workers. Compared to large-firm workers, small-firm workers typically face more limited availability of employer-sponsored insurance and higher premiums because of higher administrative costs and a more limited ability to spread risk. Small-firm workers and the self-employed are less likely than workers in larger firms to have an employer coverage offer. They also generally earn less, which makes more of them eligible for Medicaid or the ACA’s Marketplace premium subsidies. Other ACA policies such as the Small Business Health Options Program and Small Business Health Care Tax Credits aimed to enhance coverage, but take-up has been limited. The 21st Century Cures Act of 2016 created an option for small firms to make tax-advantaged contributions to help subsidize individual-market coverage for their workers. The administration of President Donald Trump is implementing policies intended to make it easier for small businesses to buy group insurance coverage for workers through association health plans or contribute to the individual-market coverage that workers purchase.

Recent studies have analyzed changes in coverage for small-firm workers and the self-employed, but little is known about how coverage has changed for these workers and their families. By including family members, we account for the availability of employer coverage through a spouse. We also comprehensively describe the relationship between working in small firms and having insurance coverage for family members.

From the Discussion

Among the subgroups we examined, from 2010–11 to 2014–15 uninsurance rates fell the most among low-income families with small-firm or self-employed workers and in families with only small-firm workers, as Medicaid and other private insurance grew. Despite gains in coverage, these groups still had the highest uninsurance rates in 2014–15, with nearly one-third of people in low-income families uninsured.

A number of factors make small-firm and self-employed workers and their family members more likely to be uninsured than individuals in families with one or more large-firm workers. Compared to larger firms, small firms in the US face significant challenges in providing affordable insurance to their employees. Small firms also have low and declining employer coverage offer rates and provide less continuity of coverage than larger firms do. In addition, small firms are less likely to offer affordable dependent coverage, which may lead families to obtain coverage from multiple sources and could reduce uptake of coverage for children (as shown in studies of Medicaid).

Small-firm workers and their families with lower incomes were more likely to be uninsured and had the lowest employer coverage rates, which suggests that the high and increasing cost of such coverage is likely a major impediment to coverage for lower-income families.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

During the development of the Affordable Care Act (ACA), it was interesting to watch Congress patch together policies to try to fill the voids in health care coverage. Although each patch helped, the patchwork model of reform still inevitably left many holes in the system. This study shows that, for low-income individuals employed by small firms, one-third of family members remain uninsured – obviously an unacceptable deficiency in coverage.

For those who support building on the Affordable Care Act as a means to fill in the gaps in coverage, they are going to have to propose specific policies that will work. Expand Medicaid? The program has already been expanded under ACA, and so how are you going to change it to target these families? An employer mandate? That was rejected for small firms because of their very tight budgets. An individual mandate? These people have low incomes, so the subsidies would have to be even greater and how far would they extend into middle-income families that are also having difficulties with paying for health insurance? Depend on lower premiums through market competition of health plans? Get real.

Not only does the patchwork approach still leave too many holes in the system, it also leaves in place the existing health care financing infrastructure with its profound administrative waste, extreme fragmentation and inefficiency, and very high costs, while leaving in place inequities and deficiencies in coverage.

We seem to be having difficulty explaining to ACA supporters that building on ACA is not only the most expensive model of reform, but it is one of the least effective in that it leaves most of the flawed policies in place. Instead of increasing costs while falling far short, with what we’re already spending we could fill in all the voids while increasing efficiency and equity in the system simply by enacting and implementing a well designed, single payer, improved Medicare for all. That would take care of not only low-income families dependent on small-firm employment, but it would guarantee comprehensive, life-long coverage for everyone else as well.

Adding a public option to this mess would do very little to fill the voids and correct the deficiencies. That is why it is important to call people out who are using the “Medicare for All” label to refer to merely adding a public option or buy-in. We have to demand that the Medicare for All label refers only to the real thing – an improved and expanded Medicare that includes absolutely everyone and is affordable for all. The public option doesn’t even come close.

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By Leah Zallman, Steffie Woolhandler, Sharon Touw, David U. Himmelstein, and Karen E. Finnegan
Health Affairs, October 2018

Abstract

As US policy makers tackle immigration reform, knowing whether immigrants are a burden on the nation’s health care system can inform the debate. Previous studies have indicated that immigrants contribute more to Medicare than they receive in benefits but have not examined whether the roughly 50 percent of immigrants with private coverage provide a similar subsidy or even drain health care resources. Using nationally representative data, we found that immigrants accounted for 12.6 percent of premiums paid to private insurers in 2014, but only 9.1 percent of insurer expenditures. Immigrants’ annual premiums exceeded their care expenditures by $1,123 per enrollee (for a total of $24.7 billion), which offsets a deficit of $163 per US-born enrollee. Their net subsidy persisted even after ten years of US residence. In 2008–14, the surplus premiums of immigrants totaled $174.4 billion. These findings suggest that policies curtailing immigration could reduce the numbers of “actuarially desirable” people with private insurance, thereby weakening the risk pool.

From the Discussion

Immigrants contributed far more in premiums for private coverage in 2014 than their insurers paid out for their care, with undocumented immigrants generating the largest per enrollee surplus. This net surplus offset a deficit incurred by US natives and exceeded total insurance industry profits by about $10 billion that year. Our 2014 findings were not anomalous: Immigrants made large net contributions in every year in the period 2008–14, with little change over time.

While immigrants’ premiums were similar to those for US natives, immigrants incurred much lower expenditures—a disparity that was present in analyses limited to working-age adults. Among immigrants, expenditures increased with duration of time in the US, a phenomenon documented previously. This may reflect worsening health habits related to acculturation, increased care-seeking behaviors, and increased educational standing with time in the US. However, because premium contributions also increased with time in the US, immigrants made a net contribution to private health insurance regardless of their length of residence in the US.

Our findings contradict assertions that people born in the US are systematically subsidizing the medical care of immigrants, particularly those who are undocumented. On the contrary, immigrants subsidize US natives in the private health insurance market, just as they are propping up the Medicare Trust Funds.

Immigrants’ subsidies to private insurance and Medicare likely reflect their relative youth and good health, as well as the reluctance of many to seek care. Policies that curtail the flow of immigration to the US are likely to result in a declining number of such “actuarially desirable” persons, which could worsen the private insurance risk pool.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Immigrants who come to the United States to work are generally relatively young and healthy and thus have little need for health care services, yet they pay payroll taxes into the Medicare Trust Funds and thus are subsidizing health care for U.S. citizens on Medicare. This study adds to that by showing that immigrants, whether or not they are documented, pay more in health insurance premiums that they utilize in health care; thus they are also subsidizing U.S. citizens through the private health insurance market.

Currently the Trump administration is considering a proposed rule that would greatly expand the guidelines for “public charge” – immigrants who use  government services. If they are deemed a public charge, the rule would be used to reduce or revoke their immigration status, perhaps even deporting them from the country in spite of otherwise having complied with immigration requirements. Obviously this could have a deleterious impact on the health of the immigrants and their families, even if they are here legally.

Perhaps the fact that they pay more into Medicare and private health plans than they receive in health benefits should warrant a new concept – “public credit.” Public credit could include other factors such as, for example, the contribution of immigrants to our economy that is significantly greater than the very modest incomes that most of them receive. This and other studies suggest that the public credit would be much larger on the balance sheet than would be the public charge. Surely deportation is not a proper expression of gratitude for the debt that we owe most of them.

The proposed rule on public charge is about to be published in the Federal Register at which time a 60 day period for public comment will begin, after which the rule will be implemented. If we wish to continue to benefit from the contributions of our immigrants, we should consider requesting that a public credit be applied as an offset against the public charge (though that might be a concept that would clash with the ethnic animus of the nationalists in the Trump administration).

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By Rob Waters
California Healthline, September 26, 2018

Whipsawed is not a medical condition, but it describes exactly how Lee Henderson feels about his on-again, off-again care at UC Davis Medical Center, a place he’s been visiting since he was a child.

For the second time in three years, Henderson is about to lose access to his primary care team at the Sacramento institution.

When Henderson had surgery there in 2015 to remove an adrenal gland that was severely elevating his blood pressure, he was covered by Health Net, the only Medi-Cal managed-care plan in Sacramento County whose members could go to UC Davis for primary care at the time.

But shortly after his surgery, Henderson learned that his insurer and the university were terminating their contract, forcing him and an estimated 3,700 other Health Net Medi-Cal members to leave UC Davis and find new primary care doctors.

Now, history is repeating itself. After briefly regaining access to UC Davis last year, when UnitedHealthcare entered the Sacramento Medi-Cal market and signed an agreement with the medical center, Henderson and 1,000 other patients are getting booted out again.

On July 25, those patients got a letter from UnitedHealth. “Dear member,” it began, “we’re writing to let you know that our Medi-Cal services in Sacramento County will be discontinued effective October 31, 2018.”

Medi-Cal, California’s version of the federal Medicaid program for low-income residents, serves 13.5 million people, about one-third of the state’s population. The vast majority of them — about 80 percent — are served by managed-care plans, in which the state pays insurers a fixed amount per enrollee to provide comprehensive care.

That contrasts with fee-for-service Medi-Cal, in which the state pays medical providers directly for services provided. Medi-Cal enrollees are generally required to sign up for managed care.

The exit of UnitedHealth from Sacramento County’s managed-care Medi-Cal program means that, once again, no Medi-Cal patients on managed-care plans in the county will be able to go to UC Davis for primary care.

At the core of the issue is money. UC Davis has complained for years about low Medi-Cal reimbursement rates. (UC Davis spokesman Charles) Casey said that in 2017 the health system absorbed more than $93 million in unreimbursed costs serving Medi-Cal patients.

(Senator Richard) Pan, who now chairs the Senate Health Committee, said the structure of Medi-Cal managed care in Sacramento, which gives enrollees the choice of multiple plans, was a lose-lose for UC Davis and UnitedHealth, because the sickest, most expensive patients wanted to be on a plan that gave them access to the medical center.

“You get all the sick people — asthma or cancer or sickle cell,” he said. “The Medi-Cal contract did not account for the fact that you have a sicker population.”

The sudden loss of access to the broad and highly skilled network of doctors at UC Davis is especially hard for patients with complex conditions, said Elaine Abelaye-Mateo, a community advocate with the Health Access Action Team of Sacramento Building Healthy Communities.

https://californiahealthline.org…

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Comment:

By Don McCanne, M.D.

Although the concept of a single payer, improved Medicare for all has become quite popular, many in the policy community and legislative bodies would prefer to continue with our existing health care financing system as modified by the Affordable Care Act (ACA). Even if it were tweaked to further expand coverage, today’s report demonstrates just one of a great multitude of examples as to why the current system is unsatisfactory.

Under ACA, more low-income Californians were enrolled in Medi-Cal (California’s Medicaid program) – a total of about 13.5 million (more than the entire population of each of 46 other states!) and 80 percent of them have been shoved into Medicaid managed care plans on the theory that it would be cheaper (by administrative fiat – California ranks 47th of all states for Medicaid payment rates) and that care would be better managed (highly disputed and likely untrue).

So what are some of the policy considerations under Medi-Cal? Perhaps above all, Medi-Cal is a welfare program and thus is chronically underfunded, failing to meet the financing requirements for the essential health care services required by the enrollees.

Investor-owned, for-profit Medicaid managed care organizations are required to make a profit for their investors, so when underfunded with a fixed capitation rate, they can profit only by decreasing care provided. As masters of innovation, there are many ways the private insurers can do that, but basically their measures impair access to health care services.

An important component of the health care delivery system is the academic medical center (AMC). Patients with more complex and long-term problems will often select plans that include an AMC in their provider networks, especially if they are already patients of that center. Adverse selection is inevitable since the plans that include AMCs will attract sicker, more expensive patients. When a Medicaid managed care program is already operating at a loss, adverse selection will increase their losses and thus force a decision to withdraw from the market. This is exactly what Health Net and then UnitedHealth did with their contracts with UC Davis Medical Center. With no UC Davis Medi-Cal contract for primary care, Medi-Cal managed care patients were left without a choice of a plan that included UC Davis. Besides, Sen. Richard Pan says, “Why is a public, state-owned university that’s running a health system not contracting with the state health plan?”

Suppose we had a single payer Medicare for all instead. First, we would not have a separate health care welfare program for low-income people without much of a political voice; we would have a single, comprehensive program for everyone. We would not have private, investor-owned, for profit corporations managing the health care funds in a manner that, by necessity (ask SEC), places investors above patients; we would have a single, publicly-funded and publicly-administered program instead. We would not have stewards trying to create barriers to health care to improve the bottom line; instead our public  stewards would be assisting patients in gaining access to the care they need. We would not have patients arbitrarily excluded from academic medical centers; instead the centers would be providing specialized services to patients equitably, based on priority. We would not have a financing system that frequently results in adverse selection with all of its consequences; risk would be borne by the public payer rather than the providers or patients. We would not have sectors of health care that were deliberately underfinanced, with its consequences as well; the national global budget for health care would be adequate to meet the needs of the nation. We would not have narrow provider networks that deliberately limit access and fragment care for strictly business purposes; patients would have their choice of health care professionals and institutions.

The academic medical center should be available to the entire community with appropriate referral made through the primary care infrastructure and the universal, integrated referral system. Under a well designed, single payer, improved Medicare for all, AMCs would be available to all, as appropriate.

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