New policy calls for adequate networks for patient access, choice

AMA Wire, November 10, 2014

The new AMA policy, which is part of a new report by the AMA Council on Medical Service, calls for health insurers to make changes to their provider networks before the open enrollment period gets underway each year. Implementing changes to provider networks at this time will help prevent patients from being stuck with plans that drop their physicians after they already have enrolled.

The policy also reiterates the need for health insurers to provide patients with an accurate, complete directory of participating physicians through multiple media outlets. These lists also should identify physicians who are not accepting new patients.

Other provisions of the new policy include:

• Promoting state regulators as the primary enforcers of network adequacy requirements. These regulators can ensure compliance with state network adequacy laws and regulations that are intended to make sure patients have access to adequate provider networks throughout the plan year.
• Calling for insurers to submit quarterly reports to state regulators. These reports should provide data on several measures of network adequacy, including the number and type of physicians who have joined or left the network, the provision of essential health benefits, and consumer complaints received.
• Calling on insurers to treat patient visits to out-of-network physicians the same as in-network visits if the plan’s provider network is deemed inadequate.
• Supporting regulation and legislation that require out-of-network expenses to count toward a patient’s annual deductibles and out-of-pocket maximums when a patient is enrolled in a plan with out-of-network benefits or is forced to go out of network as a result of network inadequacies.

http://www.ama-assn.org/ama/pub/ama-wire/ama-wire/post/new-policy-calls-adequate-networks-patient-access-choice?

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Comment:

By Don McCanne, MD

If any organization should be able to devise policies that would correct the deficiencies of narrow provider networks, it is the AMA. When you read their new recommendations, clearly they leave in place the fundamentally flawed policy of restricting patient choices of physicians. Tweaking a policy that needs to be eliminated is not an adequate response.

They speak of ensuring network adequacy, but networks are not adequate if they eliminate your primary care provider, if they require greater distances to travel in seeking care, if they limit access to specialists, if they exclude physicians at centers of excellence, or if they include any of the other restrictions that result from not having freedom to choose from all available physicians in the community and in referral centers.

Keeping provider lists current is almost impossible. Physicians often do not notify the insurers when they close their practices to new patients or when they move their offices. List changes of physician attrition (retirement, license revocation, death, etc.) or of new physicians entering the community can be difficult to keep current.

Requiring prior authorization for out-of-network services is a barrier to care, if it is even allowed at all.

One of the more important AMA recommendations is to allow the cost of out-of-network care to be applied to the deductibles and to the out-of-pocket maximums. But then there would be little reason for patients to stay in network unless they had catastrophic expenses that could expose them to large balance-billing costs. Regardless, the patient is still exposed at least to the high deductibles and high out-of-pocket maximums, creating financial hardships for many of the insured.

The AMA recently again rejected recommending single payer proposals. That’s too bad. Single payer would have taken care of not only the narrow network problem, but also the thousands of other deficiencies that are unique in our highly dysfunctional, market-oriented non-system of health care financing.

An Economic Framework For Preventive Care Advice

By Mark V. Pauly, Frank A. Sloan and Sean D. Sullivan
Health Affairs, November 2014

Abstract

Under the Affordable Care Act, preventive care measures, including vaccinations and screenings, recommended by the Advisory Committee on Immunization Practices and the US Preventive Services Task Force must be covered in full by insurance. These recommendations affect the cost of medical care. Yet neither organization explicitly incorporates measures of efficiency or cost-effectiveness in making its recommendations. To redress this shortcoming, we propose a decision-making framework for these two organizations based on the principles of economic efficiency. Our analysis suggests that routine use of a preventive service should be recommended for full insurance coverage if the service’s cost-effectiveness exceeds a socially determined threshold. For less cost-effective services, we suggest that information about effectiveness and cost should be provided to consumers by physicians or government, but the choice of care and insurance coverage for care should be made by individuals. For the least cost-effective services, the two organizations should discourage public and private insurers from covering such services and report their unfavorable cost-effectiveness.

Health And Cost Trade-Offs

It is crucial to note that the policies of ACIP and the US Preventive Services Task Force are affected by legislative and political constraints. Even with expertise and intent, and with reliance on staff to summarize information on cost-effectiveness, the two organizations are heavily restricted in their ability to incorporate costs in their decisions. Nonetheless, they are given the authority to make recommendations with potentially serious cost consequences. They are being asked to do a task that is impossible to do well. The current structure is thus unworkable as a vehicle for deciding on costly coverage. We therefore propose an alternative that could, in principle, then be implemented either by ACIP and the US Preventive Services Task Force or by some other entity.

An Economic Framework

Preventive care should be made free of user cost for several reasons. The classic reason for requiring immunizations for contagious diseases is concern about the failure of consumers to consider the benefits of prevention to others who might otherwise contract the disease from them. Such use is encouraged by insurance coverage. Another reason is that considerable evidence exists suggesting that some patients do not fully appreciate the benefits from some high-value preventive services, such as the measles vaccine. Finally, future cost reduction for other services that sometimes accompany effective prevention will be overlooked by consumers insured for those services (and by insurers and employers) if there is turnover of insured people from one insurance company to another.

Shorn of technical language and complex mathematics, the fundamental goal of economic efficiency is to provide all services worth more than their cost to users and others who value receipt of these services. In contrast, services should not be provided if they improve health but not by enough to justify their costs.

Categories Of Evaluation And Advice

Here is a way to consider possible policies. A highly desirable service may be “strongly” recommended, with the expectation that physicians will routinely offer and encourage the use of such services and insurance or public subsidies will reduce the user price to zero. Most recommended pediatric immunizations fall into this category.

There are effective preventive services that might be of limited benefit to most people’s health but are sufficiently beneficial for some people to prefer them. We suggest that recommendations in this case be “permissive.” They would emphasize to consumers the positive health benefits of the care and the need to alert them about its availability and cost. Those who attach personal value to the benefit in excess of the societal threshold would be permitted to use them or insure them, but neither subsidies nor insurance would be required.

Finally, there could be a “discouraging” recommendation. In such cases, the service may be effective but insufficiently effective to justify its cost for the great majority of people.

From the Conclusion

Given that higher premiums can be a consequence of a recommendation, it seems illogical not to explicitly consider the higher costs compared to the benefit but to be explicit about both benefits and the need to consider the options, as we have recommended. This is a comparison, we admit, that clinical decision makers are reluctant or unable to make because it requires something beyond clinical considerations, and there is no alternative under current law and policies other than inconsistent or undesirable behavior. We have instead recommended a three-tier approach based on cost-effectiveness ratios. The precise dollar values that divide tiers is a political and ultimately a societal judgment.

http://content.healthaffairs.org/content/33/11/2034.full

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Comment:

By Don McCanne, MD

During the crafting of the Affordable Care Act it was decided that prevention should have the highest priority in the delivery of health care services on the basis that it would reduce health care costs by preventing more expensive care, and, more importantly, that preventing disease is better than managing it. Although there is little evidence that preventive care saves money, preventing disease is certainly beneficial.

For that reason it was decided to require that preventive services – including immunizations recommended by the Advisory Committee on Immunization Practices (ACIP) and screening procedures recommended by the US Preventive Services Task Force (USPSTF) – be fully covered by insurance, with no cost sharing, even if the deductible had not been reached.

The concept that all health care should be a prepaid service with no cost sharing was never considered as an option – much as single payer was excluded from consideration.

Mark Pauly, one of the co-authors of this Health Affairs article, popularized the concept of moral hazard in health insurance – that it was important to require patients to directly bear at least a portion of the costs of health care in order to prevent them from obtaining care for free that they would have forgone if they would have had to pay for it in part or in full. This concept has become an absolute given amongst the health policy wonks in this nation. This “skin in the game” consumer-driven notion has so dominated the policy community that it is being expanded by ever-higher deductibles which likely are contributing to the slowdown in health care spending – an undesirable form of cost containment, as will be explained.

The greatest problem with cost sharing (deductibles, co-payments and coinsurance) is that it has been confirmed that people frequently do forgo beneficial health care when they have to pay a portion or all of the costs of that care. Several other nations with universal systems recognize that problem and thus provide first dollar coverage for health care. This problem was also recognized by Congress when it was decided that preventive services should not be discouraged by making them subject to cost sharing (although it has been shown that plans with high deductibles also cause patients to forgo free preventive services).

It appears that Professor Pauly and his colleagues cringe at the thought of dismissing the moral hazard of accepting free preventive services (free at the time of service). Thus they now propose applying the consumer-directed concept of establishing tiers of preventive services – one for full coverage, a second for full payment out-of-pocket, and a third for discouraging the use of those preventive services as not having enough value (due to inordinately high prices) for anyone to pay for them.

It seems to matter little that the ACIP immunization lists and USPSTF screening tests have undergone decades of rigorous scientific investigation and represent the state of the art in preventive services. This begs the question: How do you overuse preventive services? Rather than disrupting these services because they supposedly constitute a moral hazard it would seem much more logical to use public (government) measures to reduce excess prices, just as they do in other nations.

Of course, a single payer national health program is designed to get pricing right – providing optimal health care value for all of us.

European Observatory of Health Systems and Policies

Paying for Performance in Health Care: Implications for Health System Performance and Accountability

Edited by Cheryl Cashin, Y-Ling Chi, Peter C. Smith, Michael Borowitz and Sarah Thomson
OECD, WHO, October 6, 2014

Forward from the OECD (excerpts):

The problem is that not enough is known about whether and how P4P actually increases value for money in health systems. The evidence that P4P improves health outcomes, or even quality of processes of care, is limited at best.

(This) volume analyses the experience of P4P programmes in 10 OECD countries, selected to reflect the wide range of health system contexts and challenges across the OECD.

The findings of the volume in many ways mirror the findings of the few rigorous systematic reviews of P4P programmes, and the opinions of many leading commentators. Pay for performance does not lead to “breakthrough” quality improvements, and performance measures and other key building blocks of P4P programmes remain highly inadequate.

This volume will not provide answers to questions such as whether or not P4P works, which performance measures are most appropriate, or what is the right level of financial incentive to get results. Instead – and more importantly for real health financing policy in complicated contexts – are the insights about how P4P might be used to strengthen health system governance and strategic health purchasing to continue the shift taking place in many countries from paying for performance to paying for value.

Mark Pearson, Head of Health Division, Directorate of Employment, Labour and Social Affairs
Organisation for Economic Co-operation and Development

Chapter thirteen:

United States: California integrated healthcare association physician incentive programme

By Meredith Rosenthal

One of the first, and perhaps the largest, private pay for performance (P4P) initiatives of this era was launched by the Integrated Healthcare Association (IHA) in 2001 with eight health plans representing ten million members in California. The IHA programme is of particular interest not only because of its size, but also because it has been sustained for more than a decade and has been independently evaluated.

Results of the programme:

Performance related to specific indicators

More generally, IHA’s own monitoring reports give a mixed picture of performance improvement over time. Performance measures included in the IHA P4P programme have improved modestly and unevenly across measures, with no evidence of “breakthroughs” in quality improvement.

Programme monitoring and evaluation

Two controlled studies provide the strongest evidence of impact of the IHA initiative. These studies find that not all targeted clinical process measures of quality improved. Among the measures that could be analysed, only cervical cancer screening improved differentially among the IHA participants, and improvement was modest at best.

Equity

While there has been no systemic analysis of the impact of the IHA programme on equity, several empirical clues suggest that P4P may not have distributed its benefits equally… (I)interviews with physician group leaders revealed some concerns that the P4P programme has caused groups to avoid patients whose health of health behaviour would negatively affect the group’s performance.

Cost and savings

While no formal analyses have been reported, it is unlikely that improvements in clinical quality, health information technology, and patient experience (to the extent they have occurred) would generate saving for payers.

From the Conclusions

Another possible explanation for the weak results may be the continued expansion of the measure set and the difficulty physician organizations face in making investments in quality improvement when the targets are continuously moving. There is an obvious tension here with the desire to include a comprehensive set of measures to avoid “teaching to the test,” a narrow focus that causes providers to concentrate on a small subset of tasks at the expense of unrewarded domains, and to incorporate the best available measurement science over time.

http://www.oecd-ilibrary.org/content/book/9789264224568-en

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Designing Smarter Pay-for-Performance Programs

By Aaron McKethan, PhD; Ashish K. Jha, MD, MPH
JAMA, November 6, 2014

The idea behind pay for performance is simple. Because individuals and organizations respond to incentives, physicians whose patients achieve desirable outcomes should be paid more as an incentive to improve their performance. Yet the results of pay-for-performance programs have been largely disappointing. One argument is that neither the right set of incentives nor the right set of metrics has been identified. Another explanation, which has received far less attention, is that the right set of patients has not been identified for targeted efforts.

To the extent that higher-risk patients can be reliably identified prospectively, this information can inform the design of smarter, more targeted pay-for-performance programs. Specifically, a targeted pay-for-performance program would have, at its core, a prediction model that would identify patients who are at elevated risk of failing to meet a meaningful clinical goal or of having a bad outcome. Predictive models are not just risk-adjustment models already in use by payers to create a level playing field. Predictive models can take into account any factor that is likely to affect a patient’s chance of a poor outcome.

There is little doubt that the effectiveness of these programs will be driven, in large part, by the ability to prospectively identify at-risk patients. However, given the failure of recent efforts to meaningfully improve outcomes, testing targeted pay for performance may be worth the effort.

http://jama.jamanetwork.com/article.aspx?articleID=1934599

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Comment:

By Don McCanne, MD

Pay for performance (P4P) continues to be promoted as a means of improving quality while reducing costs. This 338 page OECD/WHO report adds to the abundance of the policy literature that shows that P4P does not achieve these goals, and may actually impair equity.

The policy community never gives up on a bad idea. In this JAMA article (access is free), McKethan and Jha suggest that we improve P4P by applying it only to prospectively-identified at-risk patients. Not only would that be a good study, but it could also result in P4P rewards that are five times the current levels. What? Greatly increase the complexity and uncertainty by testing only at-risk patients, if you could even identify them? And then depend on provider greed to drive the program? Come on!

One thoroughly tested model that would greatly reduce wasteful spending while improving quality by redirecting the savings to more appropriate care is the single payer model – a national health program. We can let the policy people go out in the alley and play their P4P games while we get serious about improving Medicare and providing it to everyone.

What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

By Marsha Gold and Giselle Casillas
Kaiser Family Foundation, November 6, 2014

This literature review synthesizes the findings of studies that focus specifically on Medicare and have been published between the year 2000 and early 2014. Forty-five studies met the criteria for selection, including 40 that made direct comparisons between Medicare health plans and traditional Medicare. An additional five studies are included, even though they have no traditional Medicare comparison group.

Summary

Despite great interest in comparisons between traditional Medicare and Medicare Advantage, studies comparing overall quality and access to care between Medicare Advantage plans and traditional Medicare tend to be based on relatively old data, and a limited set of measures.

On the one hand, the evidence indicates that Medicare HMOs tend to perform better than traditional Medicare in providing preventive services and using resources more conservatively, at least through 2009. These are metrics where HMOs have historically been strong. On the other hand, beneficiaries continue to rate traditional Medicare more favorably than Medicare Advantage plans in terms of quality and access, such as overall care and plan rating, though one study suggests that the difference may be narrowing between traditional Medicare and Medicare Advantage for the average beneficiary. Among beneficiaries who are sick, the differential between traditional Medicare and Medicare Advantage is particularly large (relative to those who are healthy), favoring traditional Medicare. Very few studies include evidence based on all types of Medicare Advantage plans, including analysis of performance for newer models, such as local and regional PPOs whose enrollment is growing.

As the beneficiary population ages, better evidence is needed on how Medicare Advantage plans perform relative to traditional Medicare for patients with significant medical needs that make them particularly vulnerable to poorer care. The ability to assess quality and access for such subgroups is limited because many data sources do not allow subgroups to be identified or have too small a sample size to support estimates. Also, in many cases, metrics employed may not be specific to the particular needs or the way a patient’s overall health and functional status or other comorbid conditions influence the care they receive.

At a time when enrollment in Medicare Advantage is growing, it is disappointing that better information is not available to inform policymaking. Our findings highlight the gaps in available evidence and reinforce the potential value of strengthening available data and other support for tracking and monitoring performance across Medicare Advantage plans and traditional Medicare as each sector evolves.

What Do We Know About Health Care Access and Quality in Medicare Advantage Versus the Traditional Medicare Program?

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An Emerging Consensus: Medicare Advantage Is Working And Can Deliver Meaningful Reform

By Thomas Miller and James Capretta
Health Affairs Blog, November 6, 2014

The success of Medicare Advantage in recent years is changing the conversation on Medicare reform.  It is now possible to envision genuine bipartisan support for fair competition between MA plans and FFS.  The “premium support” concept still engenders highly politicized opposition in some quarters.  But support for the idea has also begun to cross ideological divides. 

Premium support is of course a complex reform.  It requires risk adjustment of payments and regulation of plans to ensure fair competition.  But the risk adjustment system and the regulation need not be perfect for the reform to work; indeed, the system already in place today for MA plans should provide sufficient confidence that a competitive reform model would be beneficial for the program’s participants.

The main obstacle to more intensive competition in Medicare has been distrust.  MA advocates believe the bureaucracy will tilt the playing field toward FFS; and FFS defenders believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.

http://healthaffairs.org/blog/2014/11/06/an-emerging-consensus-medicare-advantage-is-working-and-can-deliver-meaningful-reform/

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Comment:

By Don McCanne, MD

Today two new papers were released designed to give us greater insight on the relative value of the traditional Medicare program and the private Medicare Advantage plans. What can we learn from these reports?

It is well established that Medicare Advantage plans are paid more per patient than the costs of providing care for comparable patients in the traditional Medicare program. They continue to market their plans to healthier patients and yet they artificially magnify a touch of illness for purposes of receiving greater payments based on risk adjustment. Although the Affordable Care Act requires a gradual reduction in these overpayments, concessions have been made by the Obama administration to reduce the impact of these adjustments. The taxpayers continue to receive inferior value from their investment in the private Medicare Advantage plans.

The comprehensive literature review from Kaiser Family Foundation concludes that the information available unfortunately is quite limited. They do conclude that Medicare HMOs are able to achieve higher scores in providing preventive services – likely because of their IT systems that flag items that would improve their quality rating scores. Medicare HMOs also use resources more conservatively, which raises the concern that they could be withholding appropriate care.

Perhaps the most important conclusion from the Kaiser review is the finding that the differential in quality and access for beneficiaries who are sick is particularly large, relative to those who are healthy, between traditional Medicare and Medicare Advantage. Medicare Advantage plans may have learned how to score well on teach-to-the-test quality measures, but they fall far short of traditional Medicare in patients’ real world health care experiences.

The Health Affairs Blog article by Miller and Capretta needs to be recognized for what it is – a political tract. They claim that “evidence mounts that MA plans can deliver more efficient and higher quality care than FFS” – a claim based more on their ideological preferences for a privatized Medicare rather than on a comprehensive review of the health policy literature. They then use that conclusion to advocate for a premium support proposal that would further privatize Medicare.

They state that the main obstacle to increasing public and private Medicare plan competition is distrust. They say that Medicare Advantage advocates believe that bureaucrats will tilt the playing field toward traditional Medicare, yet the facts are that the Obama administration has been tilting the field towards the Medicare Advantage plans instead. They also say that the traditional Medicare advocates “believe private plans will find new ways to risk select and game the system or to influence policymakers to provide them with overly generous terms on their payment rates.” Of course, those are not just beliefs but are well documented facts. We are paying more for private insurers to game the system at our expense.

Although neither of these reports provides new evidence that would change our opinions on private Medicare Advantage plans, they do reinforce our view that we should not listen to ideologues who care more about markets than about patients. Instead we should continue to support our traditional Medicare program that puts patients first, although we do need to improve it and then expand it to cover everyone.

This Is How the New GOP Senate Will Try to Dismantle Obamacare

By Jonathan Cohn
New Republic, November 4, 2014

Most Republicans know that they can’t repeal Obamacare anymore. They’ll start with a symbolic vote for outright repeal. From there, (Ted) Cruz says, Republicans will go after Obamacare provisions “one at a time.” 

Here’s what the GOP has in mind, based on conversations with health care experts and lobbyists:

• Repealing the individual mandate
• Repealing or modifying the employer mandate
  • changing the threshold to 40 hours
  • could propose raising (50 employee requirement) to 100 full-time employees
• Eliminating “risk corridors”
• Repealing the device tax
• Abolishing the Independent Payment Advisory Board (IPAB)
• Introducing “Copper Plans”
  • 50 percent actuarial value

http://www.newrepublic.com/article/120125/republican-plans-obamacare-device-tax-mandates-risk-corridors

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Comment:

By Don McCanne, MD

New Republic’s Senior Editor Jonathan Cohn, an astute and very well-informed observer of the health care reform scene, provides us with a quite plausible response of the new Republican majority in the next session of Congress. They will likely fulfill their promise to introduce legislation to repeal the Affordable Care Act (ACA), though knowing that the effort will end with either a filibuster or a presidential veto. The real action will take place over individual provisions of ACA.

Some of the less objectionable measures they propose could be included in other bills as part of the legislative compromise process. Other less desirable changes could avoid filibuster by being tacked onto reconciliation bills, and avoid veto by being added to must-sign bills ((e.g., bills to prevent shutting down the government).

Since the Republicans have never formed a consensus on the replace part of repeal and replace, it is unlikely that they will try to enact some of their proposed measures such as eliminating the tax preference of employer-sponsored plans, or selling plans across state borders to avoid effective regulatory oversight. Such efforts would create new problems that would be unpopular – not an approach they would likely take when they have their eye on the White House in two years.

So how does single payer activism fit into all of this? With one caveat, there should be no change in our mission to educate our colleagues and the public on a vastly superior alternative – a single payer national health program. As patients experience the deficiencies of our current dysfunctional system, they have to understand that it doesn’t have to be this way – that everyone can have their choices in essential health care without having to negotiate financial barriers to that care.

During the next session of Congress, it is clear that we will not see any movement on single payer legislation. Even if a wave of Republican Enlightenment were to flood Congress and they decided that single payer really was the preferred model, they would not allow President Obama to receive any credit by signing the bill, but rather would wait until a Republican President took office in 2017. Lest this seem like a fantasy, F.A. Hayek supported “a comprehensive system of social insurance.”

Our education process is two-fold: 1) describing the very positive features of the single payer model, and 2) exposing the severe inequities and deficiencies of our fragmented system which has only been perpetuated by ACA. The former is obvious, but the caveat applies to the latter.

Until we can move forward on single payer, it is important to take care of what we do have. We should not criticize the efforts of those who are still in the process of implementing ACA. They are doing the best they can under current laws and regulations. If Congress tries to enact measures that are clearly detrimental we should join our friends in opposing such actions. If beneficial patches to ACA are proposed, we should not oppose them merely because they perpetuate ACA, but rather support them as transitional improvements until we can achieve single payer.

But this is where we have a problem. We need to let the public know why these measures are inadequate – how they merely perpetuate our highly flawed system. But we must make a clear distinction between our efforts to make our health care system work well for everyone and the efforts of some members of Congress who would destroy as much of ACA as they can, and walk away leaving too many people exposed to yet more health and financial insecurity. When we are accused of helping the enemy of reform by opposing ACA we have to correct that misperception by letting them know that we support ACA as a transitional program that provides some relief until we can enact single payer, but that we cannot accept decades of incremental changes to ACA that can never lead to a rational, comprehensive system of health care financing.

Based on the simplistic messages that carried the election, it is obvious that we have a formidable task ahead of us. Our messages are not simple, but they need to be clear. Everyone can have affordable, high quality health care, but we do not have that with ACA nor would we with the anticipated Republican actions. We have to let people know.