Haven, accessed March 7, 2019

Haven was established by Amazon, Berkshire Hathaway, and JPMorgan Chase to bring together the resources and capabilities of the three companies to create better outcomes, greater satisfaction, and lower costs for their U.S. employees and families.

Frequently Asked Questions

Why was the name ‘Haven’ chosen?

It reflects our goal to be a partner to individuals and families and help them get the care they need, while also working with clinicians and others to make the overall system better for all.

How is Haven going to improve health care?

We are pursuing a number of common-sense fixes, as well as innovative approaches, to address issues like making primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable. We are also looking at new ways to use data and technology to make the overall health care system better.

Is Haven going to replace existing doctors or insurance companies?

We are interested in working with clinicians and insurance companies to improve the overall health care system. We will be an ally of anyone who is working to make health care better for patients.

Who is Haven going to help?

Our focus is the U.S.-based employees and families from Amazon, Berkshire Hathaway, and JPMorgan Chase. In time, we intend to share our innovations and solutions to help others.

https://havenhealthcare.com

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Comment:

By Don McCanne, M.D.

When Warren Buffett (Berkshire Hathaway), Jeff Bezos (Amazon) and Jamie Dimon (JPMorgan Chase) announced that they would join together to address the problems with our health care system, there was considerable hype that, along with their CEO Atul Gawande, these titans of the private sector would finally bring us the solutions that we needed for our overpriced and underperforming health care system.

Now that their health care venture is getting underway it is no surprise that their efforts initially will be confined to meeting the health care needs of their own employees with no involvement for the rest of the nation, except perhaps to serve an example.

Given the limits of our current dysfunctional health care system, at first glance their approach seems reasonable: improve access to primary care, improve employee understanding of the health insurance benefits, attack the high prices of pharmaceuticals, and investigate ways that data and technology might be used to improve the health care system. Although aren’t we already doing these things, albeit not equitably and not very effectively? And doesn’t this fall terribly short of the comprehensive reforms that we desperately need?

One of their proposals that stands out is the dependence on employer-sponsored private health insurance – the clarion call of the opponents of single payer Medicare for All. That implicitly supports profound administrative waste, fragmentation of health care financing, perpetuation of limited health care choices through the restrictions of provider networks, and the perpetuation of deductibles and other cost sharing that create financial barriers to care and potentially expose patients to financial hardship and even personal bankruptcy.

It would be much more beneficial for theses titans to abandon support of the current dysfunctional health care financing system, and instead advocate for a system that would solve their and everyone else’s health care problems – a single payer Medicare for All program. They would not have to do it alone, but it sure would help if they decided to participate in the orchestration of a movement culminating in a truly beneficial national health program for all of us. What an opportunity they seem to be missing. It’s shameful.

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By David J. Meyers, MPH; Emmanuelle Belanger, PhD; Nina Joyce, PhD; John McHugh, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD
JAMA Internal Medicine, February 25, 2019

From the Introduction

More than one-third of Medicare beneficiaries are now enrolled in MA (Medicare Advantage), an increase from 19% in 2007. Medicare Advantage differs from TM (Traditional Medicare) in that private insurance plans are paid by the Centers for Medicare & Medicaid Services (CMS) on a capitated basis to cover the care of their enrollees. Because payments are fixed, this model incentivizes payers to reduce spending. Medicare Advantage plans may emphasize better primary care and care management services for high-need enrollees to prevent expensive acute services down the line. Two potential barriers to these benefits exist: capitated payments when not properly risk adjusted may incentivize “cream skimming” and “lemon dropping” (ie, attracting healthier individuals and dropping those with higher needs). Medicare Advantage plans may also restrict physician networks and require prior authorization for care. These policies may be challenging for high-need enrollees, potentially leading to poorer experiences. Understanding the experiences of high-need beneficiaries enrolled in MA is vital if the benefits of managed care are to work for this group.

A growing body of literature suggests that concerns remain regarding MA plans for high-need enrollees. Although some disenrollment may be driven by error in plan choice, MA switch to TM occurs at higher rates after significant health events and kidney failure. Evidence from the nursing home industry suggests that MA enrollees have access to lower-quality nursing homes and have high rates of disenrollment after admission. The Government Accountability Office has expressed concern that sicker patients disenroll in a biased manner. This possibility is of particular concern for patients with complex chronic conditions or multiple morbidities who stand to lose the most in disruptions to continuity of care. Disenrollment is often a sign of revealed preference, perhaps even more so if disenrollment rates are differential by patient type, which might suggest that the program does not address the preferences of these enrollees with high use of medical services.

From the Results

Across all groups, high-need enrollees had the highest rate of MA disenrollment by the end of 2015, with 2.6% (95% CI, 2.4%-2.7%) non– dual-eligible enrollees leaving the highest-rated plans and 10.6% (95% CI, 10.0%-11.2%) non–dual-eligible enrollees leaving the lowest rated plans. Disenrollment rates tended to be higher among those enrolled in lower-quality plans. Full dual-eligible enrollees left MA at the highest rates, with 11.1% (95% CI, 10.6%-11.6%) leaving the highest-rated plans and 18.5% (95% CI, 17.8%-19.3%) leaving the lowest-rated plans. However, dual-eligible beneficiaries also left TM to enter MA at the high rates, with more than 15% of non–high-need, fully dual-eligible TM enrollees switching to MA during the study period.

23.0% (95% CI, 22.3%-23.9%) of non–dual-eligible, high-need enrollees in low-rated MA plans disenrolled to TM, and disenrollment was even higher at 42.8% (95% CI, 40.5%-45.1%) among comparable high-need dual-eligible enrollees. Generally, enrollees in lower-rated plans disenrolled at higher rates than enrollees in higher-rated plans. Even in 5.0-star plans, however, high-need enrollees were more likely to disenroll (4.9% [95% CI, 4.6%-5.2%] of non–dual-eligible high-need enrollees compared with 1.8% [95% CI, 1.8%-1.9%] of non–dual-eligible and 2.4% [95% CI, 2.1%-2.7%] of dual-eligible non–high-need enrollees).

From the Discussion

We find that high-need and dual-eligible enrollees have substantially higher disenrollment rates when compared with non–high-need enrollees. This finding aligns with that of the recent Government Accountability Office report on disenrollment and other recent examples from the literature that suggest that MA plans may not currently meet the preferences of high-need enrollees. We also found large movement of TM enrollees into MA during the study period, particularly among dual-eligible beneficiaries, indicating a high level of switching in this population.

Several factors may explain differential disenrollment during this study period. Although risk adjustment has mitigated some cream skimming, plans may still not have an incentive to retain their high-need enrollees, leading to adverse selection not on who enrolls in plans but on those who disenroll. The limitations (eg, narrow networks, prior authorizations, etc) enacted by MA plans to control costs may not align with the preferences of enrollees who have complex care needs. Lower disenrollment rates from high-rated plans may be indicative of these plans providing fewer restrictions in access to care or other benefits to such enrollees. Beneficiaries with better health and socioeconomic status may also be better equipped to make more informed plan choices when first enrolling in MA. High-need enrollees may select suboptimal contracts when they first enroll in the program, and, when faced with the limitations those contracts contain, may be prompted to switch more often than healthier enrollees. High-need enrollees may also be enrolled in lower-rated plans because their more serious health needs exert a downward pull on the overall contract rating.

The largest changes in enrollment status from TM to MA and from MA to TM occurred among enrollees with dual eligibility with Medicaid. This finding is likely explained in part by dual-eligible enrollees being able to switch plans at any point during the year. An interplay between a state Medicaid managed care program and an MA plan may encourage more switching.

Conclusions

We find that high-need enrollees, particularly those who are dual eligible, disenroll from MA at substantially higher rates than other enrollees. Thus, our findings suggest that caution is warranted when evaluating the performance of MA plans owing to the potential for selection bias stemming from differential disenrollment. As of now, disenrollment is only 1 of 35 to 45 measures included in the MA star ratings system. Weighting disenrollment more heavily may help incentivize plans to address these concerns further. Although MA may have the potential to provide greater care coordination to address complex patient needs, it is unclear whether high-need enrollees who stand to benefit the most from care coordination are in fact benefiting.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

The private Medicare Advantage insurers have been successful in marketing their plans, presumably because the enrollees perceive the plans to be superior to the traditional Medicare program, perhaps partly because of the touted benefits of managed care. However, this study shows that high-need enrollees, particularly those who are dual eligible (enrolled in both Medicare and Medicaid) disenroll from Medicare Advantage plans at substantially higher rates than other enrollees.

Supporters of privatization of Medicare through Medicare Advantage plans claim that patients are very satisfied with their coverage, but this report suggests that may be true only for individuals who do not have high health care needs. If they do have greater needs, they disenroll at higher rates.

Back in the days of the managed care revolution and the earlier Medicare + Choice plans, it quickly became evident that the healthy go into the plans and the sick come out. It appears that the tools of the current private Medicare Advantage plans have not reversed this trend. The plans seem to succeed primarily by keeping the low-cost healthy patients happy (lower cost sharing and extra benefits funded by the taxpayers), but shouldn’t we expect more out of our health care system?

Why don’t we improve Medicare and then expand it to cover everyone while using equitable public financing to make it affordable for each of us? Then everyone would be happy with the system, regardless of their medical needs.

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By Michael K. Gusmano, Karen J. Maschke, and Mildred Z. Solomon
Health Affairs, March 2019

Abstract

There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, “consumer-driven” health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.

Introduction

Building a health care delivery system that is more patient centered has a lengthy history, including powerful grassroots efforts beginning in the 1960s. These initiatives see patient-centered care as an important means of improving health outcomes and a morally worthy good in itself. As a means to an end, patient-centered care includes efforts to make the care delivery system more efficient and easier for patients to navigate. Patient engagement—a particular form of patient-centered care—yields better, well-documented outcomes by stimulating patients to take on more active roles in promoting and maintaining their health. As a moral end in itself, patient-centered care emphasizes the importance of honoring patients’ values and preferences, and it is less paternalistic and more respectful. Although there are concerns about how the concept might be misapplied, there is broad support for it, evidenced by federal investment in studying how best to ensure patient-centered outcomes and patient-centered outcomes research.

Increasingly, however, the focus on patient-centered care has begun to rely upon, and even merge with, the concept of patients as consumers. In this article we call for greater vigilance in distinguishing patient-centered care from the concept of consumer-driven health care. Too often consumer-driven health care is used as if it were a synonym for patient-centered care. We argue that consumer-driven care is based on critical myths about what creates, and what can rein in, high-cost care. Moreover, the consumer-driven concept can easily place the burden for systemwide cost containment on the shoulders of individual patients. In this article we offer a brief history of the patient-centered care movement, demonstrate how the language of patient-centeredness is becoming appropriated by those advocating market reforms, and then articulate why the consumer metaphor is misguided and potentially harmful.

Origins of the Patient-Centered Care Movement

In contrast to the early use of these terms to connote ways of empowering patients, consumer driven and consumerism are now associated with market-oriented health reforms that place a burden on patients to solve cost and quality problems. These consumer terms function as metaphors that represent conceptual confusion and are potentially harmful. The terms wrongly assume that health care is a competitive market and that the high cost of US health care is a function of excessive consumer demand. Because these requisite assumptions are not met, the metaphor’s remedy—price transparency and competition—cannot deliver on the promise of reducing costs or ensuring quality. Moreover, it is misleading to use consumer driven, defined in this narrow sense, as a synonym for patient centered. A consumer metaphor could also erode obligations by policy makers and health care systems to build a truly patient-centered care system.

Health Care Is Not a Market

Patients can be construed as consumers only if they are operating within a market. But health care is not a market in the usual way that markets are defined, and thus patients do not have the power that consumers have to shape that market. Patients are not as well informed as physicians are about medical care. Often patients do not have well-formed preferences, and they seek care under circumstances in which they do not have the time or emotional stamina to shop around on the basis of quality and price. And if policy makers treat health care like any other market, there will likely be very limited cost savings, if any, and huge inequities will continue and likely increase. As Nancy Tomes puts it, “this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation.

The High Cost of US Health Care Is Not Due To Excessive Consumer Demand

Policy makers in the US frequently act as if the main problem is excess volume, which in turn arises from excess patient demand. Because most patients in the US have some form of health insurance, they are insulated from the full cost of health care. Some commentators are concerned that there is a potential moral hazard, because insurance provides patients with an incentive to consume health care beyond the point at which marginal benefit equals marginal cost.

More than just a technical term, moral hazard is a concept that is normatively loaded. It suggests that health care spending is the result of policies that offer an incentive for bad behavior.

Moral hazard concerns suggest that the use of expensive hospitalizations, surgeries, and other interventions are shaped primarily by ability to pay. This perspective fails to recognize that most people consume such services only reluctantly. The use of these services is often driven by providers, not by patients. Indeed, academics and policy makers have expressed concern for decades about the reliance of the health insurance system on fee-for-service payments to physicians, hospitals, and other health care providers. Fee-for-service provides an incentive for physicians to deliver additional and more complex services than patients need (or more care than economists would view as efficient) because health care providers receive an additional payment for every additional service—and services that are viewed as more technically complex generate higher fees. In most countries outside the US, however, “provider-driven” demand is not countered by shifting costs to individual patients and asking them to control costs by acting as informed consumers in a marketplace. Instead, most countries rely on a combination of overall budget targets for health care services and systems of all-payer rate regulation in which national health insurance funds negotiate rates for hospital, physician, and other services with representatives from those professions. Because the US does not use the negotiating power of government to confront the power of providers, it pays higher prices for all medical goods and services than other countries do.

Not only is the use of market competition limited when it comes to asking patients to make efficient decisions about health care services and providers, but it also does not work well when it comes to making decisions about health insurance plans. Competition among health plans in the Medicare program was promoted as a method for reducing the costs of the program, but Medicare Advantage has not produced the intended savings. In fact, there has been some examination of choices made in Medicare Part D, suggesting that consumers do not necessarily make choices in their own best interests: Beneficiaries fail to select plans that provide better risk protection at lower cost. These findings are consistent with earlier work on choice overload and Medicare beneficiaries’ selection of health plans. The findings led economist Paul Krugman to exclaim that “‘consumer-based’ medicine has been a bust everywhere it has been tried.

While it is wise to help patients make more informed decisions about the costs of care and to grow in their ability to make quality comparisons across health systems, the main driver of health care costs is not consumer demand, but rather the introduction of new technologies and unwillingness on the part of US political leaders to regulate prices—or at least use government bargaining power as leverage to negotiate lower prices. The US relies on a system of uncoordinated payment by thousands of payers, many of which do not have the bargaining power necessary to drive down prices. This has resulted in high prices for medical services. Technological improvements in health care have driven increases in cost all over the world, but extraordinarily high prices and a refusal by government to regulate them or bargain them lower differentiate the US from other countries.

The Consumer Metaphor Could Erode Health Care Professionalism

Medical professionalism requires independent, discretionary judgment. Professionals do not simply do as they are told or requested but must act on the basis of knowledge, skill, and fiduciary obligations to patients’ well-being.

Hospitals must judge each case to find the right balance between patient and family preference and physician integrity. It seems reasonable to anticipate that as the consumer metaphor grows, physicians’ authority in these kinds of cases could erode to the point where they may become technicians doing what they are asked to do, but doing so against their own consciences.

Professionalism may also erode if physicians are more inclined to offer unproven treatments simply because patients demand them. If the customer is always right, self-restraint on the part of providers could erode.

Conclusion

After four decades of organized patient advocacy, US patients are still struggling to influence the health care decisions and policies that shape their lives. Conflating consumer approaches with authentically patient-centered approaches will exacerbate this gap. In health care delivery and health policy, a patient-centered approach affirms the ethical principles of respect for persons and justice while striving to make the health system more responsive to patients’ values and preferences. There are some patient-centered approaches, such as patient engagement and activation, that yield substantial improvements in health outcomes. Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail. It is important for policy makers and health system leaders to be vigilant in distinguishing between these seemingly similar, but different, approaches. Patient-centered approaches aim to ensure clinical care that can meet patients’ preferences and needs. That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society’s cost-containment challenges.

https://www.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

The authors are from the Hastings Center, a nonprofit bioethics research institute in New York. That is important to understand since the consumer-driven movement in health care has left out this one crucial element: ethics.

Advocates of consumer-driven health care have conflated the primacy of the patient with the patient-as-a-consumer metaphor, but the two have very little in common.

A discussion of this issue is very timely since legislation to enact a single payer Medicare for All program has been introduced in Congress. Elimination of financial barriers to care (deductibles and other cost sharing) is a fundamental feature of this model of reform. Consumer-driven models deliberately erect financial barriers to care in order to deter the use of health care services and thus reduce health care spending, but it does so at the cost of impairing access to beneficial health care services and potentially exposing patients to financial hardship. In sharp contrast, a well designed single payer model uses much more patient-friendly methods of controlling spending. Specifically, costs are contained through publicly-administered negotiated pricing and global budgeting. Pricing is high enough to ensure adequate capacity in the system yet not excessive, thereby ensuring that health care will be available and affordable for society as a whole.

As the authors conclude, we should not expect patients to solve society’s cost-containment challenges. “Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail.” Thus it is an ethical imperative to reject consumer-driven health care and move forward with an equitable, affordable system that ensures essential health care for everyone – Single Payer Medicare for All.

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Fox Business, March 1, 2019

Physicians for a National Health Program President Dr. Adam Gaffney discusses why the U.S. should move to single-payer health care system.

Nine minute Fox video:
https://video.foxbusiness.com…

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Comment:

By Don McCanne, M.D.

Considering that most of the Fox panel members were more intent on providing their own right-wing messages against single payer health care, PNHP President Adam Gaffney is quite effective in giving quick, succinct responses on Medicare for All even as he has to override the squawking Fox magpies as they try to disrupt him.

Great job, Adam.

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