ACA Deathwatch – Handicapping ACA repeal legislation

With Sen John McCain’s unexpected surgery delaying a Senate vote on the BCRA (Senate Republican ACA repeal-and-replace bill), here’s where ACA repeal stands.

Briefly, my take is Congress will not pass a repeal bill. So, the ACA Deathwatch clock’s hands turn back yet again

The core problem is the damned-if-you-do-or-don’t nature of the legislation.  By a 2-to-1 margin, Americans prefer “Obamacare” to the replacement

However, Republicans like repeal and replace. So, McConnell et al are stuck with a terrible choice – pass repeal and replace legislation that most Americans don’t want, or pass legislation that their base wants.

Add to this the strong support for ACA from several key Republican governors, and the fact that those most hurt by repeal would be core Republican voters; rural, white, lower-middle income folks, and the dilemma becomes knottier still.

A vote has been delayed indefinitely, allowing opponents – who grow more numerous by the day – to rally more opposition to BCRA.

What’s the future of repeal-and-replace? 

As of now, cloudy indeed, with a strong chance of dying with a whimper and not a bang.

What does this mean for you?

We’ll explore implications for workers’ comp of a non-vote on BCRA later this week – factoring in other legislative moves to slash Medicaid plus the non-enforcement of the mandate into our analysis.

It’s not just opioids.

Yes, opioids are the biggest problem in workers’ compensation.  Not just work comp medical, but in the entire work comp industry.

Opioids kill patients, prolong and intensify disability, ruin families, run up huge costs, and lead to myriad other problems. But opioids are far from the only problematic drug class in our tiny little world

No, we have gabapentin, Soma, and anxiolytics. But today we’re going to focus on anti-psychotics – yet another mis-used medication that is causing harm to work comp patients.  

Reportedly some prescribers are writing scripts for these drugs as an alternative to opioids or other pain medications; they aren’t required to check PDMP databases or otherwise deal with opioid-related issues when prescribing anti-psychotics. This lower “hassle-factor” may drive increased use of these medications as opioid-related prescribing legislation becomes more common in more states.

As with opioids, a big issue is the side effects…in this case, tardive dyskinesia.

  From wikipedia:

TD is a disorder that results in involuntary, repetitive body movements.vThis may include grimacing, sticking out the tongue, or smacking of the lips. Additionally there may be rapid jerking movements or slow writhing movements.[1] In about 20% of people decreased functioning results.

Tardive dyskinesia occurs in some people as a result of long-term use of neuroleptic medications (antipsychotics, metoclopramide).[1][2] These medications are usually used for mental illness…older neuroleptics [drugs]…are associated with high risk for tardive dyskinesia. (emphasis added)

The photos above are the least disturbing I could quickly locate; suffice it to say that TD is pretty horrible.  One of TD’s causes is long-term usage of antipsychotics – which, believe it or not, are becoming more prevalent in workers compensation.  A close friend who runs the pharmacy program for a top ten insurer told me prescriptions for these drugs are becoming increasingly common – and he’s now seeing scripts for drugs to treat their chief side effect – TD.

The good news is there’s now treatment for TD.  The bad news is the cost – between $125 and $150 a DAY for Ingrezza – that’s $60,000 annually. Forever.

What does this mean for you?

unintended consequences can be horrific. 

Work comp’s drug problem

Is getting a lot better, a lot faster than the rest of the world’s.

thanks to you.

I’m in the midst of conducting the 14th Annual Survey of Prescription Drug Management in Workers’ Comp, a project I began way back when no one had heard of physician dispensing, and before opioids became a national disaster. (prior surveys can be downloaded at no cost here)

Physician dispensing in comp is slowly being solved – today WCRI released a comprehensive look at the issue which is well worth your time. (members get it for free, non-members pay a modest cost)

And we’ve made good progress on the opioid front, something few other payers can assert.  Overall, I’d hazard a guess that opioid spend – as a percentage of total drug spend – declined somewhat last year; we’ll know for sure in a couple of weeks.

The latest, albeit anecdotal takeaways from a dozen surveys I’ve done so far, indicates:

  • opioid spend continues to drop with some payers reporting double-digit percentage decreases
  • much of this comes from curtailing initial and secondary scripts
  • there’s a lot still to be done to address chronic users
  • payers are using a whole array of techniques, clinical resources, and tools to address opioid overuse, with many relying on PBMs for analytics, pharmacists, and physicians for peer-to-peer discussions
  • some payers expressed concern over the various overdose-prevention medications

Do NOT take this to mean we’ve won, that we’ve solved the opioid disaster, that we can take the rest of the summer off.

Far from it.

We’ve done the easy stuff, now comes the really knotty, tough problem of helping individual patients who’ve been prescribed way too many pills for far too long get their lives and health back.

What does this mean for you?

Thanks to all of you, who, through your work in the trenches, in policy, with individual patients and physicians and pharmacies, have made things better.  You have saved countless lives and countless families.

 

 

Medicaid’s really important – even/especially to you.

Welcome back to MCM; I took a few days off posting to hit the campaign trail, where I heard a LOT of concern about possible changes to Medicaid.
Most of us probably don’t think much about Medicaid. Here’s why we should.
First, Medicaid covers the poor elderly, those who are totally disabled, and depending on the state, poor kids and families.
Second, many are really sick people or frail elderly with no other way to get healthcare.

 

Medicaid reimbursement is generally low compared to private insurance or Medicare, but that doesn’t mean access is severely limited. In fact, (about 70% of physicians do accept new Medicaid patients versus about 85% who accept new privately insured and Medicare patients) (ESI is employer insurance)

Part of the solution

Is not being part of the problem. So, I’m running for office – specifically Onondaga County Legislator, 6th District.

I’d much appreciate your support if you are so inclined – please follow on Twitter and Facebook. We’re also fundraising and accepting contributions here.

Why am I running?

One reason – our area (Syracuse New York and surrounding communities) is the worst in the nation in terms of economic opportunity.

Yes, Onondaga County has been hammered by things beyond our control – as have many cities and counties. But unlike Buffalo, South Bend or Fort Wayne Indiana, our leaders have done little but watch and squabble and talk as our communities have deteriorated, businesses moved out, and jobs disappeared.

I see the history here- a community that created an entire industry and supplied the entire country with a critical resource – salt.

A community where innovation and creativity built a hugely successful foundry – Crucible. Where giant companies built big businesses and employed thousands in well-paying jobs in autos, electronics, chemicals, heavy industry here – in Onondaga County – because they needed committed workers, robust infrastructure, and can-do government. We have one of the world’s leading research universities, and in our community we have businesses like Tessy Plastics and Welch-Allyn, two innovative, successful businesses that prove you can prosper here.

Onondaga County can – must – get back to what it was – a high-energy, powerful, creative and can-do community.

County Legislators are supposed to manage a $1.4 BILLION budget, oversee County operations, and set priorities for the County. For this they get paid about $30,000 a year (which is about the average income here), AND get New York State health and retirement benefits. All that – taxpayer paid – for going to three or four meetings a month – if they even bother to schedule and show up to those meetings (many times they don’t).

As some of my most discerning readers may have noticed, my political leanings tilt Democratic – but old party definitions don’t mean much any more. Back in the day no Democrat would take $250,000 to speak to a huge investment bank, or forgive an entire industry for causing the worst recession since 1929, or ignore what’s been happening to working class families.

And Republicans wouldn’t have dreamed of trade protectionism or violating states’ rights by forcing them to comply with other states’ laws.

Yes, I’m going to continue my day job – working with workers’ comp companies to improve patient outcomes and reduce costs for employers and insurers. I love what I do, and I really enjoy helping companies get better.

One simple and greatly appreciated way to show support if you are so inclined would be to follow on Twitter & and Facebook. We’re also fundraising and accepting contributions here.

The ACA lives on – good news for everyone

Especially congressional Republicans.

As of 4 pm on Tuesday, 9 Republican Senators have publicly stated they will vote against the Senate’s health care bill. While some want more dollars, care, and support, others want a complete repeal. This puts Majority Leader McConnell in an unwinnable position; everything he gives to the moderates upsets the hard-right Senators.

While McConnell continues to say they’ll vote on the bill after the July 4 recess, that’s unlikely.  He rammed it through in secret precisely out of fear that the longer it was in the public eye, the lower the chances for passage. Rest assured Senators will get an earful when they return home to do the parade thing.

While many Republicans will be assailed by hard-right activists for failing to deliver on “repeal and replace”, many are likely raising a toast to the gallows they just avoided.

There are two reasons for this. First, neither of the Republican bills would do anything to address the real problem – healthcare costs.  insurance costs are high in large part because healthcare in the US costs way too much and about a third of that spend is unnecessary.  So, if the bill had passed, it would have done nothing to keep costs low, and the Republicans would be getting the blame for higher premiums – as the Dems have since 2014.

More immediately, the House or Senate or some combination bill would have crushed core Republican voters – white, working class, generally older Americans. BCRA/AHCA would have led to sharply higher insurance premiums for many, while their poorer neighbors would have lost the Medicaid coverage they gained, if they are fortunate enough to live in a state that expanded Medicaid.

The average net increase for a silver plan under BCRA was, according to the CBO, 74 percent.

Older people – like me – would have paid much more than that.

And that’s why the glasses are clinking in the bars around Capitol Hill.

What’s next? Hopefully Republicans will allow Democrats into their discussions, so both parties can work on desperately-needed fixes to ACA. A great start would be telling insurers the Cost Sharing Reduction payments are going to happen. This would stabilize the current situation so they could start working on permanent fixes.

While that would be best for the country, I’m not sanguine about the likelihood that will happen. If Trump et al kill the CSRs, premiums will jump by a lot, and that could be the death knell for individual coverage.

What does this mean for you?

Here’s hoping Congress does some real live work for the people, instead of this symphony of dysfunction we’ve been witnessing for the past few years.

If it does, we’ll be in a whole lot better shape next near.

Tuesday catch-up

I’m going to announce something new tomorrow on the personal front; stay tuned for details…

Until then, here’s what I missed while doing a lot of non-work-related stuff over the last couple of weeks.

Medrisk has launched telerehab, a new service designed to deliver therapy and related services direct to patients at their worksite or home.  I’m a big fan; used appropriately telerehab can help patients heal faster and ensure their home exercises are performed correctly and consistently. (MedRisk is a consulting client).

Medical leadership at Broadspire is changing hands. Dr Marcos Iglesias is taking over from the estimable Dr Jake Lazarovic; Dr Jake has been at Broadspire for as long as I can remember.  He’s always been a pleasure to speak with; humble, highly observant, innovative and focused on always doing the right thing.  Dr Jake has long been one of the good people in our industry.

Dr Iglesias is a friend as well; Marcos has deep experience in occupational medicine as both a provider and insurance company clinical leader.

The first segment of Coventry’s annual drug trend report is out; key takeaways are:

  • opioid utilization dropped 8.5% from 2015 – 2016
  • Average Morphine Equivalents per script decreased 5.6%
  • Total drug costs were down 5.8%

This is yet more evidence that PBMs and payers are doing really good work in cutting employers’ costs and patient risks.  Note to regulators – this is happening across the country; please don’t do things that will hamper PBMs’ efforts to ensure patients get the right drugs.

An excellent review of where the dollars flow in pharma from HealthAffairs; note this is for ALL pharma, not just workers comp or health insurance. (chart from HealthAffairs)

WCRI’s released a series of reports on worker outcomes, following on the heels of an assessment of workers’ comp income benefit adequacy.  WCRI has been focusing on outcomes and worker satisfaction for some time now; kudos to John Ruser and predecessor Rick Victor for this important work.

Finally, a really interesting piece from Harvard Business Review on how some very large employers are dumping health insurers and buying healthcare direct.  I will predict this is going to happen more frequently, and is a big risk for the big four healthplans.  

Health Wonk Review update

Friday I inadvertently left out two excellent posts from long time contributors Hank Stern and Roy Poses Md PhD.

My apologies to these gentlemen, and here’s a very brief UPDATE – with their contributions.

Hank Stern, contributed a post about the Defense Base Act, and a contractor’s…challenges when encountering the Act…DBA is kinda like workers comp without the unlimited benefits…and this poor soul suffered mightily.  Hank delves into the details as to how this could happen.  The brief answer – all too easily.

Healthcare in the occupational arena is often the  forgotten red-headed stepchild of the healthcare world, yet it is a significant issue for both the workers who sustain what can be life altering workplace injuries and employers who bear the full cost burden for medical care and wage replacement. At Workers’ Comp Insider, Tom Lynch offers a primer of best practices in his Eight Steps To Controlling Workers’ Compensation Costs part 1, part 2 and part 3.

Roy Poses provided a different perspective on health care, asking why people with no healthcare background are running health care delivery organizations.  

from Roy’s post…

I believe that managerialism in a health care context (leadership of health care organizations by people with only management training, and without any knowledge, understanding or experience in health care, based only on management dogma) is one of the major causes of health care dysfunction. Here is a great example of a managerialist hospital CEO who also seemed to demonstrate the Dunning-Kruger effect, that people who lack ability are likely unaware of this lack…To belabor the obvious, true health care reform requires health care leadership that understands health care and upholds its professional values.

An interesting post to juxtapose comes fromJason Shafrin, who asks “Does more spending improve outcomes?” 

number of studies have claimed that increasing health expenditures may result in no better, or even worse patient outcomes.  The Healthcare Economist revisits the topic looking at the case of neonatal ward spending and patient outcomes in the UK.

HWR – The double edition

You get more for your money this fortnight!

The Senate Republicans’ release of their repeal-and-replace bill – plus our usual plethora of wisdom from health care experts, gives you a double-value today – the first in the history of HealthWonkReview!

Part One – Repeal-and-Replace

Let’s be real – Republican Senators’ bill is NOT an ACA replacement, rather it is best understood as a major reduction in Medicaid. For some, that’s all to the good; for others, not so much.

Here’s what you need to know.

(note I looked for other blog posts supporting the Senate bill – if you read any good ones please send them to me)

From Forbes, Avik Roy says

“the Senate bill will have far-reaching effects on American health care: for the better….if you simply kept [some tax credits from the House bill] in force, and tossed overboard the Paul Ryan flat tax credit, you’d solve all of these problems with the House bill. By making that change, the near-elderly working poor would be able to afford coverage, and the poverty trap would be eliminated. [emphasis added]

I wholeheartedly disagree with Roy’s premise. logic, and selective use of data to support his contention. He just doesn’t understand healthcare and the delivery thereof. His contention that eliminating coverage for 20 million Americans is “for the better” is patently absurd.

Andrew Sprung at xpostfactoid cut to the chase – his takeaway is the bill trades Medicaid coverage for high deductible private market coverage.  Andrew quotes Louisiana Republican Senator Cassidy…but notes Cassidy’s sentiment is misleading at best.

Right now, [low income people] might have a $6,000 deductible, which for someone who makes 150 percent of the federal poverty line might as well be $6 million. 

Sprung…

It’s true, as Cassidy avers, that an enrollee with an income of 150% FPL [federal poverty level] might have a $6,000 deductible, but most don’t…In any case, “most of those 20 million” who newly gained coverage did so through the Medicaid expansion and have zero deductible.

Ezra Klein made a similar point even more economically at Vox – “The Senate GOP health bill in one sentence: poor people pay more for worse insurance.”

Margot Sanger-Katz’ New York Times piece entitled G.O.P. Health Plan Is Really a Rollback of Medicaid reminds us of Kaiser Family Foundation reporting that Medicaid covers :

  • 20% of all Americans
  • almost half of all births, and
  • two-thirds of nursing home residents.

David Williams pushes things a bit further with his post, asking if we should consider Medicaid for all. David uses Nevada as a “template” for his assessment of the potential that  when – my words not his – the GOP destroys ACA – there will be an open revolt and we’ll end up with single payer – using Medicaid. 

Compelling case…

Timothy Jost and Sara Rosenbaum on Health Affairs Blog give us “Unpacking The Senate’s Take On ACA Repeal And Replace“; here are a few key quotes…

  • the Senate bill…entirely strikes the House bill and adopts a new bill with a new title.
  • the Senate bill is focused on changes to the Medicaid program.
  • parts of the Senate draft will be challenged under the Byrd rule. (they violate rules allowing passage without 60 votes)
  • the Senate bill would replace the House’s age-based premium tax credits (APTC) with tax credits based on age, income, and the actual cost of health insurance in particular markets.

Wrapping up our Medicaid – ACA – BCRA discussion, AHCA’s unkindest cuts is from healthinsurance.org; The premise:

The attention various AHCA provisions get is inversely proportionate to the damage they’ll do. and that the bill — and its likely Senate counterpart — should properly be called the Medicaid Dismemberment Act.

Nate Silver opines on the likelihood of BCRA’s passage – his considered opinion is: 

I’d guard both against interpretation that the bill will necessarily pass the Senate because it passed the House. At the same time, Ryan and House Republicans overcame some of the same obstacles — and if that precedent isn’t dispositive, it’s at least highly relevant.

Part Two –

UPDATE – apologies to Hank Stern, who contributed a post about the Defense Base Act, and a contractor’s…challenges when encountering the Act…DBA is kinda like workers comp without the unlimited benefits…

Healthcare in the occupational arena is often the  forgotten red-headed stepchild of the healthcare world, yet it is a significant issue for both the workers who sustain what can be life altering workplace injuries and employers who bear the full cost burden for medical care and wage replacement. At Workers’ Comp Insider, Tom Lynch offers a primer of best practices in his Eight Steps To Controlling Workers’ Compensation Costs part 1, part 2 and part 3.

Roy Poses provided a different perspective on health care, asking why people with no healthcare background are running health care delivery organizations.  

from Roy’s post…

I believe that managerialism in a health care context (leadership of health care organizations by people with only management training, and without any knowledge, understanding or experience in health care, based only on management dogma) is one of the major causes of health care dysfunction. Here is a great example of a managerialist hospital CEO who also seemed to demonstrate the Dunning-Kruger effect, that people who lack ability are likely unaware of this lack…To belabor the obvious, true health care reform requires health care leadership that understands health care and upholds its professional values.

An interesting post to juxtapose comes fromJason Shafrin, who asks “Does more spending improve outcomes?” 

number of studies have claimed that increasing health expenditures may result in no better, or even worse patient outcomes.  The Healthcare Economist revisits the topic looking at the case of neonatal ward spending and patient outcomes in the UK.

Are the exchanges failing? well, depends on who you ask…

Louise Norris has become one of the nation’s leading experts on ACA and exchange matters; she tells us Nevada has a unique approach to their MCO contracts, and the result is that all of their current exchange insurers filed plans for 2018, and two new insurers have also filed QHPs to be sold on the exchange in the fall.

Health Access California’s reports that while Congress considers cuts and caps to Medicaid, California is showing a stark contrast in investing in this core health care program, restoring benefits like dental and vision, and using tobacco tax money to increase provider rates.

CMS Meaningful Use Payments to Providers: Incentives or Sophie’s Choice?is what I love about HWR; really smart, intelligent, deep thinking about what really drives healthcare.

For healthcare providers who are caught in the Meaningful Use regulatory net by participating in the program, they were given a choice between installing an electronic health record system, attesting to meeting a list of nearly-impossible targets to get reimbursement for their multi-million dollar investments, or choosing not to participate which resulted in losing participation in government-funded programs and incentives. Most providers bit. They had no choice. And when it came time to collect the Meaningful Use incentive dollars, they attested to meeting at least the minimum requirements. Now, the government has bitten back asking for repayments of $729 million.

This is Neil Versel’s obituary of Larry Weed, who invented the problem-oriented medical record and the SOAP note, and had been advocating for the computerization of medicine and the inclusion of patients for at least 60 years. One of the leading change agents in healthcare, and one we would do well to think about as we try to drive change

Adam Fein’s entry focuses on the wonders of charity care, and providers thereof.  I did not know that “Pharmaceutical Manufacturers Operate the Biggest U.S. Charities…”

Dr Fein’s post says in part:

growth [of Patient Assistance Programs] is linked to pharmacy benefit designs that shift prescription costs to patients. Many insured patients face economically-debilitating coinsurance—in some cases with no limit on out-of-pocket expenses. The programs are an imperfect, but necessary, fix to our imperfect drug channel system.

Finally, I wondered why the Senate Republicans were so secretive about their healthcare bill, and now we know.

From HealthAffairs blog, a trenchant piece reflecting on the ways the AHCA would harm efforts to address the opioid crisis includes this

Because of the ACA, an estimated 26 million people have health coverage through the marketplaces or Medicaid that includes substance use disorder (SUD) treatment and prevention…Repealing the ACA will remove coverage for SUD treatment and prevention from millions of Americans, leaving a gap in care when it is most needed.

Whew…

Thanks for reading, and hope your weekend is splendiferous!

The Senate version of AHCA – What to watch for

Senate Republicans are set to release their revised American Health Care Act today – here’s what we know about their version, and what to watch for.

An excellent summary is here.

Medicaid – the biggest, most significant, and most important changes are to Medicaid.

74 million Americans are covered by Medicaid, and about 2/3rds of Medicaid funds go to elderly and disabled Americans.  Reportedly the Senate bill will:

  • eliminate Medicaid expansion funds over several years, and
  • significantly reduce future federal funding for Medicaid

As a result, more than 14 million low-income, disabled, and elderly Americans will lose coverage for nursing home care, rehabilitation, and all other healthcare services.

Individual and employer mandate

The mandate would be effectively repealed by eliminating enforcement. Today individuals and employers with more than 50 FTEs have to provide coverage or pay a penalty. Note – there has never been a requirement that employers with fewer than 50 workers provide insurance.

Insurance subsidies for lower-income Americans

The Senate version reportedly has preserved some of the current income-based subsidy provisions, unlike the House bill.

Pre-existing condition coverage

Cloudy would best describe what we know about the Senate bill’s approach to ensuring people with pre-existing conditions are covered. There just aren’t enough details, however even if pre-ex conditions must be covered, it appears insurers will be able to charge much higher premiums for those with pre-ex conditions, and/or exclude treatment for those conditions from their insurance policies.

Benefits

There are mandatory benefits in ACA; these would be eliminated in the Senate version, so your insurance plan might not cover mental/behavioral health and addiction coverage, and/or coverage for different types of care such as physical therapy or hospital services. While this provision would likely reduce premiums, it reduces coverage as well.

Tax changes and the federal deficit

All ACA-related tax increases are repealed with the exception of the Cadillac tax on high-value insurance plan, a change that will substantially increase the federal deficit.

Unforeseen implications – job loss

There’s been far too little coverage of one of the most important impacts of AHCA – the loss of close to a million jobs if this is signed into law. While employment would increase over the very-near term, over the next few years it will drop as fewer people have insurance and thus can’t get care.

What does this mean for you?

Millions of Americans will lose their health insurance, smaller hospitals will close, and cost shifting will explode as providers try to stay in business.

I don’t see the bill – in it’s current form – passing. But we are close to ACA’s death than we were a few weeks ago.