Marketplace Plans Covering Out-Of-Network Care Harder To Find

By Michelle Andrews
Kaiser Health News, November 6, 2015

Health plans that offer coverage of doctors and hospitals outside the plan’s network are getting harder to find on the insurance marketplaces, according to two analyses published this week.

Two-thirds of the 131 carriers that offered silver-level preferred provider organization plans in 2015 will either drop them entirely or offer fewer of them in January, an analysis by the Robert Wood Johnson Foundation found. Those cutbacks will affect customers in 37 states, according to the foundation.

Preferred provider organization plans, or PPOs, typically offer coverage for doctors and hospitals that aren’t in the plan’s network, but require consumers to pay a larger share of the cost. In contrast, health maintenance organizations, which make up roughly half of the plans offered on the exchanges, generally don’t cover any care provided outside the plan’s network.

Last year, many insurers shrunk the networks of providers in the plans that they sold on the marketplace.

http://khn.org/news/marketplace-plans-covering-out-of-network-care-harder-to-find/

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A Tale Of Two Deliveries, Or An Out-Of-Network Problem

By Erin Taylor and Layla Parast
Health Affairs Blog, November 3, 2015

As co-workers and first-time moms-to-be, we shared much of the pregnancy journey together — including the same employer-sponsored health insurance plan. We even delivered within weeks of each other at the same hospital. For both of us, the key to managing the pain of labor and delivery was the epidural delivered by our anesthesiologists.

When it came to paying the bill, our hospital experiences diverged in one key way. Layla received an unexpected bill for $1,600 for anesthesiology services and warned Erin to expect the same. Yet Erin’s bill never came. Layla happened to deliver on a day when an out-of-network anesthesiologist was on call, while Erin was seen by an in-network anesthesiologist.

Patients who have gone out of their way to ensure they receive care at an in-network facility should not be surprised by bills for involuntary out-of-network services. One solution would be to require that all providers offering care at an in-network facility are included in the plan’s network. Absent that, a few policy changes in the current system could be a step in the right direction.

Make It Transparent

Hospitals could have patients preregister for a planned stay and work with the insurance company to provide each patient with the estimated total expected charges.

The key change here is that the estimated charges would include physician services for in- and out-of-network services. This approach would require the hospital to be straightforward with prospective patients regarding the likelihood of care being provided by out-of-network physicians

Make It Simple

Physician bills and insurance statements need to be simplified.

Clearer explanations of charges, reasons the insurance company did not pay the full amount, and why the patient is being charged would help consumers better understand their bills — and help prepare them to pay them.

Make It Available

Researchers and policymakers have questioned the limited hospital and physician networks in the ACA health insurance marketplaces, as these networks provide access to a smaller set of providers.

Some states, such as Texas, New York, and Louisiana, are tackling out-of-network billing, while legislation was recently introduced in Congress that would place limits on the ability to bill patients for out-of-network services provided at in-network hospitals.

Clearly spelling out expected health care costs, and the likelihood of out-of-network charges, would go a long way toward reducing the economic uncertainty associated with hospital stays — and help patients understand the billing statements they receive after discharge.

Blog Comment by Don McCanne, submitted but not published:

Our particular model of health care financing – a dysfunctional, fragmented, public and private multipayer system – is the most expensive way to finance health care, characterized especially by profound administrative waste. Trying to patch this system only adds further to the administrative complexity – in this case, the effort to create transparency and special handling of out-of-network charges and billing.

Modeling of health care financing systems has shown that the least expensive and most efficient are the national health service and single payer models. Considering our public support of Medicare, the single payer model would be the most feasible for the United States.

With the high numbers of uninsured and under-insured, with the reduced choice of care due to narrow networks, and with the increasing exposure to financial hardship due to shifting of risk to patients, we really do need to abandon the ACA experiment and move forward with a well-designed single payer system.

http://healthaffairs.org/blog/2015/11/03/a-tale-of-two-deliveries-or-an-out-of-network-problem/

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Comment:

By Don McCanne, M.D.

One of the more nefarious methods that private insurers use to reduce their responsibility to pay for health care is to refuse to pay for health care services provided outside of the networks of contracted physicians and hospitals that they, rather than the patient, have selected. They have tightened the screws by shrinking these networks and by dropping some of the PPO plans which permitted at least some out-of-network coverage, but at reduced rates.

As the anecdote presented in the Health Affairs Blog indicates, limited networks can be quite unfair. The two authors of the blog, a policy researcher and a statistician employed by RAND, showed how the same employer-sponsored plan covered obstetrical anesthesia for one but not for the other, simply because by chance one anesthetist was in-network and the other was not.

Recognizing the unfairness of this, the authors recommend some policy changes. They recommend more transparency so you would at least know that the services would not be covered, though it would require more administrative services to obtain and communicate that information. They recommend that bills and insurance statements be “simplified,” though they are actually asking that additional information be required to clarify the network status of each provider involved – more administrative activity. They also suggest that legislation be passed to require special handling of out-of-network charges – yet more administrative complexity.

Unfortunately, this demonstrates the flawed approach to problems with our health care financing system that permeates the health policy community today. They accept as a given our fragmented system of financing health care, as modified by the Affordable Care Act. Their policy approach avoids carefully defining the fundamental problem and moves on with mere patches to our highly dysfunctional system. As this example indicates, the patches typically compound the problems, especially by adding more administrative tasks to our system that is already sinking with administrative overload.

So what is the fundamental problem with narrow networks? It should be obvious. They are designed to benefit the private insurer by shifting more costs to patients who unavoidably or inadvertently obtain care outside of networks. This is not for the benefit of patients; it is detrimental to patient care. Health financing systems should be designed to benefit patients, not multibillion dollar corporations.

So the fundamental problem is the existence of the narrow networks. They need to be eliminated. Along with the narrow networks, all of the other profound administrative excesses that uniquely characterize the American health care financing system need to be eliminated as well. They need to be replaced with an efficient single payer financing system.

Although the Health Affairs Blog posted numerous responses more or less commending the authors for their astute policy recommendations, they did not post my response which happened to be a proposal that would actually prevent the out of network injustices. For that reason, I have included it in today’s message so that it would have at least some limited public exposure. Fortunately, they did post a response by Thomas Cox PhD RN who calls for a single national health insurer.

Physician spending and subsequent risk of malpractice claims: observational study

By Anupam B Jena, Lena Schoemaker, Jay Bhattacharya, Seth A Seabury
BMJ, November 4, 2015

Conclusions

Despite evidence that the majority of US physicians report practicing defensive medicine, no evidence exists on the broader question of whether greater resource use by physicians is associated with fewer malpractice claims. Our findings suggest that greater resource use, whether it reflects defensive medicine or not, is associated with fewer malpractice claims.

Discussion

Despite evidence that many physicians practice defensive medicine to reduce the risk of malpractice claims, no evidence exists on the broader question of whether a greater use of resources by physicians is associated with a reduced risk of such claims. We investigated the association between average resource use by physicians and subsequent malpractice claims. In six of seven specialties, we found that greater resource use was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. For example, internists in the highest fifth of patient risk adjusted resource use were less than half as likely to face a future malpractice claim compared with those in the lowest fifth. Among obstetricians, those with higher caesarean rates — a procedure sometimes considered to be defensively motivated — had lower subsequent rates of alleged malpractice. These relations held even when we adjusted for patient characteristics and accounted for time invariant physician characteristics such as patient mix, clinical skills, or communication skills.

http://www.bmj.com/content/351/bmj.h5516-0.full.pdf+html

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Comment:

By Don McCanne, M.D.

Much has been written about the high costs of defensive medicine – excessive health care services that are delivered merely to protect against the potential of malpractice lawsuits. This study tends to reinforce the belief that there is a solid basis for defensive medicine since higher spending on health care is associated with fewer malpractice claims. But does this additional care represent defensive medicine, or does it represent beneficial health care services that prevent adverse outcomes?

Although physicians admit that they practice defensive medicine, do they really do so strictly because of fear of lawsuits? Or do they do so because there is a real possibility that the patient may experience a significant adverse outcome because of the physician’s failure to detect or manage a serious medical condition? Invariably the latter concern plays at least some role in the medical decisions made.

Imaging is probably the most common procedure that is thought all too often to represent defensive medicine, especially when you consider how many results are normal. But if the physician is 100 percent certain that the imaging procedure will not demonstrate any pathology, then she would not order it since she could not be sued for a condition that does not exist. Imaging is ordered only when there is a real possibility of an abnormal finding, even if the odds are low.

When physicians order low yield tests they often think of them as defensive medicine. But as physicians back off on low yield testing, the incidence of missed pathology increases, as does the risk of a malpractice suit. Thus the test that picks up significant pathology is a beneficial health care service and really should not be categorized as defensive medicine only because it also has that benefit. The same reasoning applies to a test that provides the benefit of reassurance that the potential pathology is not demonstrated.

With concerns about the very high costs of health care, many recommend that we do something to reduce all of this unnecessary defensive medicine. The problem with that is, for the reasons mentioned, not much of health care falls into the category of pure defensive medicine that is of absolutely no clinical value. Therefore there is not much savings to recover. You can talk about flat of the curve medicine or low yield medicine, but as soon as you start eliminating care, you sacrifice the health and well being of a few of your patients, not to mention that you deprive many others of the reassurance they would have from a negative test.

Another point is that so called defensive medicine is a very small percentage of the $3 trillion we are spending on health care, and we can afford that. After all, much of it is still beneficial.

If we really want to reduce waste, we should eliminate the profound administrative excesses of our dysfunctional, fragmented, multi-payer system, by adopting a single payer national health program. We would recover hundreds of billions of dollars that way. That is in contrast to this study that shows that spending more on patients is associated with a lower incidence of lawsuits. Whether we label that defensive medicine or beneficial health care services, we are not going to find much savings there.

Physicians Decry Broken Promise of Medicare Raise in 2016

By Robert Lowes
Medscape Medical News, November 3, 2015

The law that repealed Medicare’s sustainable growth rate (SGR) formula for physician pay called for an annual raise of 0.5% from 2016 through 2019 as part of a transition to value-based reimbursement.

When Congress passed the law in April, some leaders of organized medicine noted that the modest raise lagged behind the inflation rate, but said it was better than nothing. It was certainly better than the disastrous 21% pay cut that the SGR formula would have triggered in 2016. Medical societies sold their membership on the legislation, called the Medicare Access and CHIP Reauthorization Act (MACRA), in part by saying it would stabilize Medicare rates for several years.

However, the promised raise of 0.5% turned into a 0.3% pay cut in the fine print of the final 2016 Medicare fee schedule released last week. The reason? The Affordable Care Act (ACA) and several other laws that set Medicare reimbursement policy trumped MACRA.

Organized medicine isn’t taking it too well.

“Physicians were told that they would get an increase, and they’re not,” said Wanda Filer, MD, president of the American Academy of Family Physicians (AAFP). “It’s a morale breaker.”

In its 2016 fee schedule, the Centers for Medicare and Medicaid Services (CMS) walked through the math that produced the tiny pay cut in 2016. (For a fairly detailed explanation, click on the Medscape link below.)

Organized medicine saw the stealth pay cut coming in the 2016 fee schedule when it was released in draft form last summer for public comment. At that time, CMS said that its misvalued codes initiative had reduced fee-for-service spending by roughly 0.25%. In response, medical societies such as the AAFP, the American College of Physicians, and the American Medical Association, as well as the Medical Group Management Association (MGMA), urged CMS to tweak its methodology for essentially repricing codes and calculating the savings so it could hit the 1% target and avoid canceling the MACRA raise. MGMA called the agency’s approach “narrow.” The association recommended, among other things, that CMS base its calculations on a broader group of repriced codes than what the agency used.

In the final fee schedule issued last week, CMS stood its ground. “We continue to believe this approach is appropriate and compliant with statutory directives,” it said. The agency repeatedly stated that it was bound by “current law” — in other words, MACRA, the ACA, PAMA, and ABLE.

Halee Fischer-Wright, MD, the president and CEO of MGMA, said her group is “extremely disappointed that CMS failed to meet the [1%] target set by Congress.”

“Instead, CMS’s inaction will result in an across-the-board cut to physicians in 2016,” Dr Fischer-Wright said in a statement given to Medscape Medical News. “For all the ambitious plans touted by the agency to move Medicare toward a value-based payment system for physicians, its inability to adequately review misvalued codes under current fee-for-service calls into question how CMS will be able to implement far more sophisticated payment models in the future.”

Primary care physicians will feel the 0.3% Medicare rate cut more keenly than their specialist peers, said AAFP president Dr Filer.

“I think primary care physicians are working a minimum margin and working frequently at a deficit,” she said. “Practice costs haven’t declined, and primary care has been undervalued for a very long time.

“Any cut is a financial hit.”

The comments from Dr Filer and Dr Fischer-Wright stand in contrast to what the White House says about MACRA on its website: “At last, the doctors who care for seniors and many Americans with disabilities will no longer have to worry that about the possibility of an arbitrary cut in their pay.”

http://www.medscape.com/viewarticle/853878

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SGR Fix: APMs threaten physician burnout (RAND)

Comment by Don McCanne, M.D.
Quote of the Day, March 24, 2015

HR 1470, which Congress is scheduled to approve in only two days (March 26), would replace the flawed Sustainable Growth Rate (SGR) method of determining Medicare payments with a new Merit-based Incentive Payment System (MIPS). MIPS introduces considerable administrative complexity which would be a great burden to physicians, but the legislation allows physicians to opt out of MIPS by joining Alternative Payment Models (APMs) such as Accountable Care Organizations (ACOs) or Patient Centered Medical Homes (PCMHs). This RAND study of APMs reveals that physician members of APMs are at very high risk of BURNOUT.

https://www.pnhp.org/news/2015/march/sgr-fix-apms-threaten-physician-burnout-rand

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Comment:

By Don McCanne, M.D.

Earlier this year medical societies celebrated their success in helping to get Congress to eliminate the Sustainable Growth Rate (SGR) formula – a formula that could have resulted in a 21% reduction in Medicare payments – and replace it with a 0.5% yearly increase for the next few years. There are two important stories here.

The first is that SGR would be replaced with a new onerous Merit-based Incentive Payment System (MIPS) which would be used to push physicians into Alternative Payment Models (APMs) such as Accountable Care Organizations (ACOs) or Patient Centered Medical Homes (PCMHs). At that time RAND warned that physician members of APMs are at very high risk of burnout. Trading an SGR formula that was never enforced for a career in misery is hardly a rational move. But at least they got a 0.5% raise, or did they?

The second important issue is that CMS has reneged on the legislated promise of a 0.5% increase and instead is reducing rates in the traditional fee-for-service Medicare program by 0.3%. This is part of a long-term strategy to control Medicare spending by keeping rate increases below the rate of inflation. Over time, physicians have been struggling to meet expenses of caring for their Medicare patients and still have anything left to take home, with inflation eating away at their payments.

But more than that, this decision appeared to represent one more example of CMS supporting the privatization of Medicare. We have reported several examples of CMS overriding the legislated mandate to reduce overpayments to private Medicare Advantage (MA) plans. Each year they have been able to use administrative chicanery to convert the mandated reduction into an increase in payments for the private MA plans. But this year they are also using administrative chicanery to convert the legislatively mandated increase in payments into a decrease in the traditional FFS Medicare program.

Another example is that the government has reneged on their mandate to pay the costs that exceeded the risk corridors for the CO-OP plans, contributing to the financial collapse of over half of them this year. Although the CO-OPs were not Medicare plans, they were quasi-public plans that were designed to compete with the private insurers. Do you really believe that the government can readily find funds year after year to shore up the private Medicare Advantage plans, but in the first year of the CO-OPs they are incapable of finding more than 13% of the mandated funds to support risk corridor losses for these organizations?

Our government, under the Obama administration, is actively moving towards privatization of our public insurance programs. Under the private insurers we are seeing higher costs, impairment of access, financial hardship for patients, and no improvement in quality or outcomes.

We need single payer, but we also need to elect responsible stewards for our public programs.

Rising morbidity and mortality in midlife among white non-Hispanic Americans in the 21st century

By Anne Case and Angus Deaton
Proceedings of the National Academy of Sciences, published online before print on November 2, 2015

Abstract

This paper documents a marked increase in the all-cause mortality of middle-aged white non-Hispanic men and women in the United States between 1999 and 2013. This change reversed decades of progress in mortality and was unique to the United States; no other rich country saw a similar turnaround. The midlife mortality reversal was confined to white non-Hispanics; black non-Hispanics and Hispanics at midlife, and those aged 65 and above in every racial and ethnic group, continued to see mortality rates fall. This increase for whites was largely accounted for by increasing death rates from drug and alcohol poisonings, suicide, and chronic liver diseases and cirrhosis. Although all education groups saw increases in mortality from suicide and poisonings, and an overall increase in external cause mortality, those with less education saw the most marked increases. Rising midlife mortality rates of white non-Hispanics were paralleled by increases in midlife morbidity. Self-reported declines in health, mental health, and ability to conduct activities of daily living, and increases in chronic pain and inability to work, as well as clinically measured deteriorations in liver function, all point to growing distress in this population. We comment on potential economic causes and consequences of this deterioration.

From the Discussion

Although the epidemic of pain, suicide, and drug overdoses preceded the financial crisis, ties to economic insecurity are possible. After the productivity slowdown in the early 1970s, and with widening income inequality, many of the baby-boom generation are the first to find, in midlife, that they will not be better off than were their parents. Growth in real median earnings has been slow for this group, especially those with only a high school education. However, the productivity slowdown is common to many rich countries, some of which have seen even slower growth in median earnings than the United States, yet none have had the same mortality experience. The United States has moved primarily to defined-contribution pension plans with associated stock market risk, whereas, in Europe, defined-benefit pensions are still the norm. Future financial insecurity may weigh more heavily on US workers, if they perceive stock market risk harder to manage than earnings risk, or if they have contributed inadequately to defined-contribution plans.

A serious concern is that those currently in midlife will age into Medicare in worse health than the currently elderly. This is not automatic; if the epidemic is brought under control, its survivors may have a healthy old age. However, addictions are hard to treat and pain is hard to control, so those currently in midlife may be a “lost generation” whose future is less bright than those who preceded them.

Significance

Midlife increases in suicides and drug poisonings have been previously noted. However, that these upward trends were persistent and large enough to drive up all-cause midlife mortality has, to our knowledge, been overlooked. If the white mortality rate for ages 45−54 had held at their 1998 value, 96,000 deaths would have been avoided from 1999–2013, 7,000 in 2013 alone. If it had continued to decline at its previous (1979‒1998) rate, half a million deaths would have been avoided in the period 1999‒2013, comparable to lives lost in the US AIDS epidemic through mid-2015. Concurrent declines in self-reported health, mental health, and ability to work, increased reports of pain, and deteriorating measures of liver function all point to increasing midlife distress.

http://www.pnas.org/content/early/2015/10/29/1518393112.full.pdf

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Comment:

By Don McCanne, M.D.

In recent years concerns have been raised about the increases in death rates from prescription pain medications, but the magnitude of the problem was not recognized until this landmark study was released yesterday. Midlife deaths from poisonings with alcohol and drugs or from suicide of white, non-Hispanic men and women in the United States have skyrocketed since 1999. Morbidity likewise has increased in this group.

The intensity of the problem can be easily visualized by clicking on the link above and looking at Figure 1. The mortality curve of US white non-Hispanics, ages 45-54, is moving upward as the curves for US Hispanics and for residents of six other wealthy industrialized nations are continuing downward.

Although the other nations have more egalitarian, accessible and affordable health care systems, that alone cannot explain the differences since Hispanics in the United States have not seen this same isolated increase in mortality.

The authors suggest that the decline in economic security that began in the early 1970s may be an important factor. Not only have wages stagnated, but retirement security has diminished with a shift from defined benefit to defined contribution pension plans. Lack of higher education has been especially associated with this phenomenon of higher mid-life morbidity and mortality.

A single payer system would help by improving access to preventive health, mental health, and drug treatment services. But we need to do more. We need public policies that distribute the gains in productivity to the workers rather than to the rentiers, plus tax policies that reduce the injustices of income and wealth inequality. We need to ensure adequate education opportunities for all, including industrial arts and training for the service industries, along with assurances of adequate incomes in those fields. In general, we need policies that serve the social good.

To do that we need political leaders who are dedicated to the health and welfare of the people and who would enact policies to ensure that. We need to displace our current political leaders who have dedicated themselves to supporting the military-industrial complex (through more warfare), the medical-industrial complex (through prioritizing support of insurers and pharmaceutical firms above the interests of patients), and the rentiers of Wall Street who are redistributing wealth from the masses to the magnates.

Obamacare Premiums Climb, But Insurers Struggle for Profit

By Zachary Tracer
Bloomberg Business, October 30, 2015

Many people shopping for health coverage this weekend on the websites created by Obamacare are going to see double-digit percentage increases in their premiums. That’s still not enough for some insurers.

Anthem Inc. says there remain competitors in the government-run marketplace offering premiums that aren’t enough to profitably provide the coverage patients will require. Prices in some areas probably will have to climb in 2017 and even 2018 to reach levels that make sense, according to Chief Financial Officer Wayne Deveydt. Meantime, Anthem will sacrifice market share to keep its plans profitable, he said.

“When you have fewer national enrollees and you have price points that we don’t believe are sustainable, we’ve just made a conscious decision we’re not going to chase it,” Deveydt told analysts on a conference call on Wednesday. “We are going to need to be patient until this works itself out.”

Deveydt’s remarks spotlight a problem for the Patient Protection and Affordable Care Act’s marketplaces as the third annual sign-up period begins Sunday. Set prices too low to lure customers, and losses can mount. Some smaller firms already have closed, and some bigger insurers have withdrawn from markets — such as Aetna Inc., which will offer coverage in two fewer states this year.

The conundrum has led to this year’s price increases, which have been higher, on average, than last year’s hikes. But the danger is that premiums are now too expensive for some families to afford coverage, especially the uninsured people the Obama administration is trying to persuade to shop on the exchanges for the first time.

But the remaining uninsured are poorer and younger than those who’ve already signed up, and they’re more difficult to reach, Health and Human Services Secretary Sylvia Mathews Burwell has said. That may mean slower growth for the insurers.

Charles Gaba, who tracks the health law on ACASignups.net, estimates that the rate increases across the U.S. will average about 12 percent to 13 percent, based on a weighted average of current enrollment.

“Some of the large carriers are having pretty significant rate increases,” said Jeff Smedsrud, who runs the private insurance shopping site Healthcare.com.

Price isn’t the only challenge for insurers, according to Shawn Guertin, Aetna’s CFO. Membership levels are lower than expected, and some individuals are sticking with pre-Obamacare plans, cutting into the size of the market. There’s also been lots of churn — customers signing up and then dropping their policies throughout the year.

Aetna hasn’t been turning a profit in Obamacare plans, the company has said. Guertin said its price hikes range from high single digits to the mid-teens, depending on the market. UnitedHealth Group Inc., the largest U.S. health insurer, has said its premium increases are in the double digits as well.

http://www.bloomberg.com/news/articles/2015-10-30/obamacare-premiums-jump-but-insurers-still-struggle-for-profit

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Comment:

By Don McCanne, M.D.

The performance of competing private insurance plans within the ACA exchanges is not much different from the performance of the pre-ACA private plans in the individual market. Trends in higher insurance costs, greater cost sharing, and narrower choices were already occurring, and they continue to grow progressively worse. Access and affordability can only suffer.

Higher premium credits and out-of-pocket subsidies are helping individuals with incomes near poverty levels, but, for middle-income families, they are inadequate to provide much benefit.

Higher premiums and more cost-shifting to patients are adequate to maintain profits for most larger insurers, but where even these measures are inadequate, insurers are pulling out of the exchanges, and some of the smaller insurers are even folding. Market manipulations create instability.

The insurers show their true colors through statements such as that of Anthem’s Chief Financial Officer Wayne Deveydt. Reporting to Wall Street analysts, Deveydt said about the market, “When you have fewer national enrollees and you have price points that we don’t believe are sustainable, we’ve just made a conscious decision we’re not going to chase it.”

Higher premiums, greater cost-sharing, narrower networks – the behavior of the private insurers is not changing in spite of the promise of higher value and lower costs through the ACA Marketplaces. The ACA exchanges are a creeping failure that is growing worse.  Congress enacted the wrong model of reform. We need single payer.

Editorial: End of Arches points to single-payer

The Salt Lake Tribune, October 29, 2015

The collapse of Utah’s cooperative insurance provider, the Arches Health Plan, was not unforeseen, either by those who favor the Affordable Care Act or those who have always hated it.

Count Utah’s Sen. Orrin Hatch among the latter.

Hatch’s preferred alternative, the Patient CARE Act, has the advantage of not being Obamacare. But it is at least as complex as the ACA, shifts more costs onto consumers and more work onto states. Worst of all, passing it would force millions of Americans who have finally found health care under the current law back to square one.

Which is what just happened to 63,000 Utahns who will have to find new coverage now that Arches has tanked.

All of this fiddling with rival steampunk assemblages of subsidies, mandates, taxes, exchanges and co-ops continues to burden Americans because Republicans have never accepted, and Democrats have never fully sold, the realization that a country where millions of people do not have access to affordable health care is the skunk in the garden party of First World nations. No truly civilized society would tolerate such a condition.

The establishment of non-profit co-ops was one of many unsatisfying compromises between those who wanted a single-payer, Medicare-for-all design — or, at the least, a government-run public option — and those who irrationally trusted the private sector to provide what it simply is not willing or able to provide, now or ever, affordable health care for all.

The original ACA had funds to back the co-ops if — when — they ran out of money. But the Republican-controlled Congress, frustrated by many failed attempts to repeal Obamacare outright, cut back on the guarantees. So at least 10 such organizations around the country have now failed.

Meanwhile, premiums continue to rise and the private insurance sector is consolidating as big firms are bought by bigger ones. There is less and less of the competition that reformers of all ideological stripes were hoping, some with more faith than others, would keep costs down.

What Obamacare opponents do not seem to grasp is that, if it doesn’t work, if the co-ops fail and the exchanges don’t meet the needs of working families, going back to a pre-ACA jungle will not be a workable or ethical option.

It’ll be single-payer, or at least a robust public option. As it should have been from the beginning.

http://www.sltrib.com/opinion/3111523-155/editorial-end-of-arches-points-to

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Comment:

By Don McCanne, M.D.

What a great opener for this weekend’s national meeting of Physicians for a National Health Program. An editorial in The Salt Lake Tribune tells us that, as we see the failures of the co-ops, the inadequacies of the exchanges, and “rival steampunk assemblages,” it should have been single payer from the beginning.

They mention, “or at least a robust public option.” But lost in the prior enthusiasm for the public option was the fact that it would not have been an adequate solution since it would have been only one more player in our highly dysfunctional, fragmented health care financing system. But this does not reduce the impact of their message since the prevalent belief was that the public option would eventually lead to single payer (a highly unlikely event since it would not have fundamentally altered the highly flawed, complex financing infrastructure). So their intent is certainly well meaning.

Yes, single payer, as it should have been from the beginning.

Adequacy of Outpatient Specialty Care Access in Marketplace Plans Under the Affordable Care Act

By Stephen C. Dorner, MSc; Douglas B. Jacobs, ScB; Benjamin D. Sommers, MD, PhD
JAMA, October 27, 2015

In this study of federal marketplace plans, nearly 15% completely lacked in-network physicians for at least 1 specialty. We found this practice among multiple states and issuers. This likely violates network adequacy requirements, raising concerns regarding patient access to specialty care. Such plans precipitate high out-of-pocket costs and may lead to adverse selection (ie, sicker individuals choosing plans with broader networks), which is similar to concerns over restrictive drug formularies.

We also found substantial turnover in directory listings. This may contribute to inaccuracies in listings, which prompted more stringent federal requirements for 2016. However, physician listings without any specialists (even if inaccurate) may confuse or impede consumers’ access to physicians.

(R)ural regions are known to have fewer physicians and may have an even higher prevalence of specialist-deficient plans.

http://jama.jamanetwork.com/article.aspx?articleid=2466113

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Comment:

By Don McCanne, MD

This study shows that not all health plans in the ACA insurance exchanges have a full complement of specialists in their networks. When patients have to obtain their care out of network, they may face impaired access and financial penalties. If private insurers cannot provide the basics, why would we want to include them in our health care system in the first place?

Single payer.

Brief Comments on ColoradoCare

By Ida Hellander, M.D., David U. Himmelstein, M.D., and Steffie Woolhandler, M.D., M.P.H.
Physicians for a National Health Program, October 27. 2015

Organizers for the ColoradoCare ballot initiative have contacted some activists in Physicians for a National Health Program seeking their endorsement and financial support. We summarize, below, our understanding of the initiative.

Description of the program

ColoradoCare is a ballot initiative for a publicly financed, universal health plan for the state of Colorado that would be operated by a private cooperative under a 21-person elected Board. While the ballot measure spells out the program’s governance and Board structure in considerable detail, key aspects of the program are not specified, and/or left to the discretion of the Board. In the past the drafters made clear in public statements that ColoradoCare is NOT a single-payer plan.

The initiative would cover all Colorado residents under a publicly funded, cooperative insurance plan. While the new program would replace most private insurance, Medicaid and CHIP coverage, it would serve only as supplemental coverage for those covered by Medicare, the VA and TriCare. The initiative would not prohibit the purchase or sale of private coverage duplicating the public plan. However, proponents expect that little private insurance would persist, since most businesses and individuals would not want to pay twice for coverage.

The proposal would cover a broad range of benefits, but would not cover dental care for adults, or long-term care for most individuals.

ColoradoCare would be funded via a payroll tax of 6.67 percent on employers and 3.33 on employees, or 10 percent of non-payroll income (excluding pensions and annuities), along with federal funds that would have come to the state via subsidies for private coverage under the Affordable Care Act, for Medicaid, and for other programs.

The drafting of ColoradoCare was spearheaded by Colorado Sen. Irene Aguilar and psychologist Ivan Miller. Volunteers and paid staff gathered the signatures necessary to put it on the ballot. Journalist T.R. Reid has become a champion and spokesperson for the plan both inside and outside of Colorado.

Strengths of ColoradoCare

1. The proposal if implemented would cover all, or nearly all of Colorado’s uninsured – apparently (and laudably) including the undocumented.

2. The proposal includes some useful cost-control features, notably the creation of an annual budget, and the ability to negotiate lower prices with pharmaceutical companies.

3. The plan allows for a free choice of primary care doctor.

4. The financing plan is more progressive than the current system.

5. ColoradoCare’s organizers have mounted an impressive campaign with considerable mobilization.

Weaknesses of ColoradoCare

1. Multiple payers would persist – probably including private insurers. As a result, it sacrifices much of the administrative savings that could be realized through a true single-payer reform because providers would have to maintain much of their current cost tracking and billing apparatus in order to apportion costs among the multiple payers. Published cost estimates for ColoradoCare overstate the savings that could be achieved through single payer, and do not take into account the additional costs entailed by ColoradoCare’s failure to adopt a full single-payer structure.

2. The initiative makes no mention of how hospitals or other institutions would be paid – apart from a rhetorical nod favoring ACOs. It makes no mention of global budgeting, separating operating and capital payments, or other constraints on hospital capital spending. Global budgeting is critical to achieving administrative savings; separating operating and capital payments is a bedrock of effective health planning, which is essential for long-term cost containment.

3. The initiative would not ban for-profit hospitals or other providers, despite clear evidence that they inflate costs and compromise quality. For-profit ACOs (indistinguishable from HMOs in most respects) might also flourish.

4. The initiative specifies that patients would have a free choice of primary care physicians, but makes no mention of whether the choice of specialist or hospital could be restricted.

5. While the plan would outlaw deductibles, the Board would be empowered to impose copayments.

6. While the 10 percent tax rate would apply to both the rich and poor (including those with incomes below the poverty line), income over $350,000 would not be taxed.

7. The campaign’s anti-government rhetoric is problematic.

8. Rather than specifying critical aspects of the plan, the initiative leaves many of these to be decided later by the Board. Delaying such decisions has often favored corporate interests, who can intervene after the popular mobilization required to pass a reform has subsided. In the case of the ACA, corporate lobbying during the rule-making process attenuated cuts in Medicare HMO overpayments; reduced promised funding for public health and community clinics; effectively neutered limits on insurance overhead; and watered down the mandated benefit package. In Vermont, the broad-brush program initially passed by the legislature was whittled down in the detailed design stage, leading to rising cost estimates and ultimate rejection by the governor.

Dr. Ida Hellander is director of health policy and programs at Physicians for a National Health Program. Drs. David Himmelstein and Steffie Woolhandler are internists, professors at the City University of New York School of Public Health, lecturers in medicine at Harvard Medical School, and co-founders of PNHP.

https://www.pnhp.org/news/2015/october/brief-comments-on-coloradocare

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Comment:

By Don McCanne, MD

Until the nation supports a political environment in which a bona fide single payer national health program can be enacted, it is wise for activists to advance beneficial health policies that can reduce suffering and hardship on an interim basis. Until then, PNHP will continue to carry out its mission of educating the public as we advocate for a single payer system. As others continue with their efforts to improve the system, we encourage them to simultaneously actively support the golden standard of a single payer national health program. All of us share the common goal of health care justice for all.