Nov
9

Updates on the ACA

With the GOP attorneys general’s case to overturn the ACA pending before the Supreme Court, you may want a refresher on what the ACA is, where it is working and when it isn’t, what the problems are.

And more importantly how we can fix it.

One of the nation’s leading experts on the ACA- Charles Gaba – will cover all that stuff tomorrow in a webinar.

The Milbank Quarterly will also be publishing experts’ views on the ACA.

As I mentioned last week, Biden will likely be limited to administrative orders, as the GOP-run Senate (pending the Georgia runoff) is not likely to help him implement structural improvements.

What does this mean for you?

A lot of boring wonktalk about the ACA which is nonetheless really important.

 


Nov
6

Friday catch up

Election week in America – the never-ending show continues…

Here’s what else happened this week.

Online registration for the CompLaude awards opened up; you can sign up here for the December 3 virtual event. Congratulations to all the nominees.

The fine folk at WCRI continue to pump out relevant research; I have a lot of catching up to do but did manage to dive into their analysis of New York’s work comp systems and the results thereof. Quick takeaways:

  • Medical inflation has been pretty flat since 2014, driven by decreasing costs for non-hospital providers. You read that right; costs dropped by about 1 percent per year from 2014 – 2019.
  • Hospital outpatient payments per claim went up 2 percent per year over that period
  • Drug costs in the Empire State have dropped by 9 – 12 percent per year, driven by
  • a 48% drop in morphine equivalents per claim, and a 23 point decrease in the percentage of claims with an opioid script.

Way to go New York.

Addiction treatment

A great piece in WaPo about contingency management, a treatment approach that is yielding promising results. Essentially it rewards drug users with money and prizes for staying abstinent. Some folks don’t like it on moral grounds; they feel its wrong to reward addicts for staying clean.

I’m no ethicist, but this strikes me as a reasonable objection. However, it has to be balanced against the good that comes from helping people recover. Critics’ high morals kind of pale in comparison to keeping people alive.

For now, only the VA is paying for this. It’s long past time private insurers and Medicare/Medicaid stepped up.

All things COVID

I haven’t been paying nearly enough attention to the eruption of COVID; will do a couple posts next week to catch up.  In the meantime, here’s treatment news.

From MedScape, good news; it appears the risk of cardiovascular problems in young athletes recovering from COVID isn’t as high as once thought.

Okay, that’s the good news. The not-good news is the most common version of the virus has mutated and is now more contagious. However, we appear to have dodged a bullet – this version of the virus also mutates much more slowly than other common viruses. It’s really hard to attack a virus that’s constantly changing as scientists are constantly playing catch up.  A relatively stable virus means the development of vaccines and treatments should be a lot more productive.

Lastly, there’s been a lot of misinformation that doctors and hospitals are over-counting COVID cases because they make more money. In a word, that’s a lie. Hospitals do not receive extra funds when patients die from COVID-19. 

Miscoding patients and deaths would be fraud and could result in criminal prosecution.

For the relatively small percentage of patients that don’t have health insurance, there is Federal money available, HOWEVER, healthcare providers can only submit claims that list covid-19 as a patient’s primary diagnosis. Patients with COVID often die of sepsis and other conditions; in those cases providers get paid nothing.

Net – there is zero evidence to support that assertion. None whatsoever.

I find this incredibly offensive; one of our daughters is a nurse working in a major hospital and her husband is a clinician at a VA facility. 1700 healthcare workers have died of COVID – 200 of them are nurses.

These lies are reprehensible.


Nov
5

Enough obsessing…here’s what the election means for healthcare.

Like many, I’ve been spending far too much time obsessing over election results.

It’s a waste of time and energy…and completely useless; rather than dive into Maricopa County absentee ballot trends, time is far better spent figuring out the election’s implications.

I’ll stipulate that come January there will be a Democrat in the White House, a Democratic majority in the House of Representatives, and probably a very narrow Republican majority in the Senate (although that depends on Georgia’s Ossoff – Purdue results and the Warnock – Loeffler runoff).

Here’s what this means for healthcare.

The ACA is here to stay – whether it gets fixed is up to the Senate.

The Affordable Care Act needs work, but gridlock may keep it stumbling along.

Biden’s wish list includes:

  • lowering the eligibility age for Medicare to 60,
  • allowing the federal government to negotiate with pharmaceutical companies over prescription drug prices,
  • spending $775 billion on caregiving to address the need for home health,
  • expanding financial assistance for health insurance,
  • creating a “public option” government health plan, and
  • changing the individual mandate to ensure folks are incentivized to get health insurance.

Without a Democratic Senate, much of the list (lowering Medicare age, public option, $ for caregiving) is unlikely to happen...but Biden can use Executive Orders to address some key problems.

Expect a slew of Orders on issues including:

  • expanding family planning services;
  • expanding value-based care to – perhaps – include pharma (a backdoor way to partially address drug costs);
  • free and expanded testing for COVID,
  • transparency on medical billing, and
  • a mechanism to address surprise bills.

A Biden Administration will double down on the opioid crisis, taking much more aggressive action to make profiteers such as Purdue pay huge penalties. Criminal charges may well be levied against those profiteers along with efforts to reclaim dollars parked overseas by the Sackler family (owners of Purdue).

Of course, this depends on the Georgia runoff, scheduled for January 5 with early voting starting December 20.

What does this mean for you?

Its a lot more productive to focus on the implications and how they may affect you, your family, your community and your business than to worry about stuff we can’t control.


Oct
28

The Sturgis Superspreader Event

Increasing evidence points to August’s Sturgis motorcycle rally as a major contributor to the big increase in infections throughout the upper midwest.

With 400,000 folks spending days talking, drinking, eating, recreating, socializing, dancing, singing, and generally having a great time – mostly without masks, sanitizer and obviously with no social distancing, this should come as no surprise.

Sturgis’ Meade County has experienced a major jump in case infection rates, helping to steepen South Dakota’s infection curve.

Using phone tracking data, researchers found:

counties that contributed the highest inflows of rally attendees experienced a 7.0 to 12.5 percent increase in COVID-19 cases relative to counties that did not contribute inflows.

Sturgis’ location in South Dakota was problematic as the state has done little to encourage responsible behavior, choosing to allow individuals and local entities to decide on public health measures.

The study has been met with some criticism, however other reports indicate outbreaks linked to Sturgis attendees happened in Colorado, Minnesota, Washington, New Jersey, North Dakota and other states.

One can argue about the validity of this study or pick apart specific issue, but one cannot justify 400,000 maskless people mashing together in the midst of a pandemic.

None of us like to be told what to do – me included. The idea of someone telling me what to wear, where I can and cannot go, things I can and cannot do…is why I’ve worked for myself for 25 years.

With that freedom comes responsibility, and the freedom-loving folks who went to Sturgis likely robbed thousands of others of their freedom to live COVID-free.

What does this mean for you?

We are all in this together – for good or ill.

Thanks to Pete for inspiring this post.

 

 


Oct
6

Opioids – Deaths up, Sacklers likely to escape justice

Three news items hit the desk, ranging from bad to awful.

More than 73,000 of us died of drug overdoses in the 12 months ending February, 2020. That’s four thousand more deaths than the previous year.

(note graph below is for a slightly different time period)

And it is getting worse.

Preliminary data indicates the death count is up 13% so far this year.

The number of non-fatal overdoses in Vermont tripled this year, with almost 9 out of 10 involving fentanyl.

Meanwhile, the drug dealers directly responsible for much of the horror are about to escape with most of their billions in ill-gotten gains intact.

The drug dealers are the Sacklers, owners of Purdue Pharma. Purdue developed and marketed OxyContin; A recent study,  authored by the Wharton School, Notre Dame, and RAND reported “the introduction and marketing of OxyContin explain a substantial share of overdose deaths over the last two decades.”

This from a New Yorker article:

Behind the scenes, lawyers for Purdue and its owners have been quietly negotiating with Donald Trump’s Justice Department to resolve all the various federal investigations in an overarching settlement, which would likely involve a fine but no charges against individual executives. [emphasis added]

A lawsuit indicated over the last few years, the Sackler family has transferred billions of dollars offshore, effectively protecting those assets from the US justice system. This from the New Yorker:

In a deposition, one of the company’s own experts testified that the Sacklers had removed as much as thirteen billion dollars from Purdue.

The states have asserted in legal filings that the total cost of the opioid crisis exceeds two trillion dollars. Relative to that number, the three billion dollars that the Sacklers are guaranteeing in their offer is miniscule. It is also a small number relative to the fortune that the Sacklers appear likely to retain, which could be three or four times that amount. [emphasis added]

This country has jailed millions of poor people for decades for drug-related crimes; the Trump Administration appears poised to let the white-collar drug dealers most responsible for the opioid crisis walk away with billions of dollars they made addicting America.

What does this mean for you?

The Sacklers should rot in hell, but they will likely live on in unimaginable luxury. We should all be outraged.

 


Sep
29

If the Supreme Court kills “Obamacare”

With President Trump’s nominee for the Supreme Court all but confirmed, there are huge implications for healthcare. If the Court rules the ACA/Obamacare is unconstitutional, “a host of provisions may be eliminated” including:

  • protections for people with pre-existing conditions,
  • subsidies to make individual health insurance more affordable,
  • expanded eligibility for Medicaid,
  • coverage of young adults up to age 26 under their parents’ insurance policies,
  • coverage of preventive care with no patient cost-sharing, and
  • lower drug costs for seniors using Medicare’s drug benefit.

Today, a brief summary of the court case and analysis of two major implications.

A week after the election the Court will hear the Trump Administration and Republican State Attorneys General argue that the entire ACA/Obamacare must be struck down. Health policy nerds (guilty!) will recall that lower courts ruled that Congress’ elimination of the individual mandate killed the entire ACA; this is the Trump/Republican AGs’ argument.

Democratic Attorneys General have argued that the mandate can and should be separated from the rest of the ACA.

We don’t know how the Court will rule. We do know that after Barrett’s confirmation, the Supreme Court will have a 6-3 supermajority of conservative justices. According to HealthAffairs, writing about the lower court’s ruling, Judge Barrett “does not clearly state her own view but signals support for the dissent’s view (full invalidation of the ACA).” [emphasis added]

Seniors and Hospitals will be dramatically impacted if the Supreme Court overturns the ACA/Obamacare (we’ll address other implications tomorrow).

Seniors

Ending the Medicaid expansion will eliminate benefits for seniors and others in Medicaid expansion states with incomes just above the poverty line.

The ACA closed the “doughnut hole” in the Medicare drug plan, saving a million seniors about $3,200 each. If it is overturned, seniors with high drug costs to treat chronic diseases such as MS, hepatitis C, some cancers, and some autoimmune diseases will see much higher costs.

Hospitals

Many hospitals are already in financial distress, especially in rural areas and states that did not expand Medicaid.

Tennessee and Texas lead the nation in hospital closures, with one-fifth of the Lone Star State’s rural hospitals already closed or close to it. Just north, a grassroots movement in Oklahoma driven by closure of a half-dozen rural hospitals, is gaining traction.

While Becker’s reports all but one of the hospitals going belly up are in states that didn’t expand Medicaid. 

If the Court overturns the ACA/Obamacare, many more rural and smaller hospitals will shut down, leaving healthcare deserts behind.

(Work comp is also affected – albeit indirectly)

What does this mean for you?

If you are a senior concerned about the cost of drugs, and/or live in a rural area, the Court’s decision will have real consequences.

 


Sep
25

Friday catch up

Pre-existing conditions, drug development, COVID-related GI problems, and marketing screwups…

First up, pre-existing conditions

Yesterday President Trump issued an executive order affirming “it is the official policy of the United States government to protect patients with pre-existing conditions.”

Well, yeah. It is today, because the ACA/Obamacare – which specifically protects patients with pre-existing conditions – is the law of the land, despite dozens of GOP efforts to overturn it. 

Couple other key issues.

  1. Without legislation signed into law, the Federal government – and the President – can’t enforce a “policy”.
  2. The executive order wasn’t released, so we don’t know what it actually says.
  3. The Trump Administration backs a lawsuit that would overturn the ACA and thereby eliminate pre-existing condition protections. 

What this means – don’t watch what someone says, watch what they do.

For more details on GOP and Democratic healthcare plans, click here.

Super-useful research on healthcare prices paid by private healthplans – kudos to RAND for updating their ongoing analysis. RAND compares prices paid by privately insurers – including work comp – to Medicare, allowing you to compare relative prices for individual facilities.

Thanks to Michael Costello for the link.

One takeaway – HCA hospitals are pretty expensive…(you can find prices for pretty much any hospital on RAND’s map)

Drug development

Pretty much all new drugs developed over the last decade relied on research you – the taxpayer – paid for.

That includes $6.5 billion of taxpayer dollars invested in remdesivir, one of the very few drugs found to be useful in treating COVID19.

COVID19

Alarming piece in JAMA yesterday reported patients with Acute Respiratory Distress Syndrome caused by COVID19 are at significantly higher risk for major gastrointestinal problems. Pretty solid science behind the research.

An earlier article highlighted the opioid epidemic during the COVID19 pandemic; there are definite limitations to the research due to small sample size and possible clinician bias. With those provisos, key takeaways include:

Good news – J&J will start Phase 3 trials of its vaccine. Unlike some other vaccines, it is a single shot and can be stored in a refrigerator for up to 3 months (others require two shots and must be stored at ultracold temps).

Marketing malfeasance

And lastly, an excellent article in the Harvard Business Review about marketing in current times.  A critical takeaway – do NOT just talk about social responsibility; DO it. Kudos to Starbucks; after mandating that workers could not wear anything with Black Lives Matter while working, the company realized it screwed up and reversed course.

For the umpteenth time, if you do screw up, apologize fully and without dissembling.  None of these “I’m sorry if anyone is offended” non-apology apologies; from the article:

With “cancel culture” as pervasive as it is, a one-time reaction is as good as letting an issue get ahead of you. Instead, treat apologies or mea culpas as the first steps of an ongoing dialogue designed to bring about thoughtful and meaningful progress.

Here’s hoping the White Sox turn things around in the upcoming series with the Cubs…and your team wins this weekend.

Be well.


Sep
21

The most ridiculous thing I ever heard.

You Bet Your Life was a 1940’s radio quiz show featuring comedian Groucho Marx; contestants vied for prizes and cash.

If you or your family members have pre-existing medical conditions, the election is a reprise of the show – Republicans want to end coverage for pre-ex, and Democrats will keep that coverage in place.

If the Trump Administration’s Texas lawsuit backed by Republican Attorneys General succeeds, you can lose coverage for pre-existing conditions if you change healthplans, switch jobs, move, marry, divorce, or have a child. If Trump and Republicans win the case in Texas;

Briefly, Republican Attorneys General have sued to overturn the ACA, and the Trump Administration is aggressively supporting the suit.  The Trump Administration and AGs’ claim the entire law must be thrown out because the individual mandate — a penalty imposed on people who chose to remain uninsured – was killed by the Republican Congress in 2017.

In so doing, it would end protections for those with pre-existing conditions.

Make no mistake, if Trump et al win the suit and you have to change health insurance plans, you are at real risk of losing coverage  – or having to pay so much you can’t afford it.

Despite President Trump’s assertions, there is No Republican plan to assure those with hypertension, diabetes, a history of heart disease, cancer, anxiety disorder, or any other health condition will be able to afford health insurance.

If you just won lotto, you’re all set. If not, you’re screwed.

Ignore Trump’s claims that there is a replacement plan in the works because:

What they do have is bait-and-switch.

As Groucho would say about the Republican claim they’ll cover your pre-ex;

What does this mean for you?

If you or a family member have a pre-existing condition, this election is about you.

If you aren’t sure, here’s a list.

And if you think you can hide your condition, you can’t. 


Sep
9

The Biden Healthcare plan explained – briefly

Healthcare will be the most significant near-term impact of this election.

If Joe Biden wins and the Dems take the Senate, here’s what we can expect.

Biden’s healthcare plan addresses the biggest problems with the ACA (known to some as Obamacare).

  1. Individual health insurance plans are way too expensive.
  2. About a third of all states didn’t expand Medicaid
  3. The big insurers have little competition.
  4. Medicare – and Medicare recipients – are paying far too much for drugs

Briefly, the Biden Plan would:

  • Cap individual health insurance premiums at 8.5% of income
  • Set up a public option like Medicare anyone could buy into
  • Allow 60-65 year olds to buy into Medicare
  • Have Medicare negotiate drug prices with manufacturers
  • Solve the Medicaid expansion problem by covering low-income folks in non-expansion states through a Federal program
  • Ban surprise medical billing for insureds that require out of network hospital care
  • Ensure pre-existing conditions are covered

The additional costs would be paid for in part by savings (e.g. drug costs) and abolishing the capital gains tax break for those making more than a million dollars a year. (More detail on this plan, along with pros and cons – is here.)

Does this solve the ACA’s problems?

It’s not a cure-all, but Biden’s plan does go a long way to fixing the ACA’s two biggest problems – healthcare is still unaffordable and prices are still too high.

For most families covered under the plan, healthcare costs would likely decrease significantly. The 8.5% cap on insurance costs is a major change as insurance premiums in many areas are north of $12,000 a year.

Healthcare providers would:

  • Scream if folks now covered by private insurers switched to a Medicare-type program as reimbursement would drop;
  • Cheer if a lot more patients had health insurance; hospitals’ indigent care costs are escalating rapidly

The real problem with healthcare costs in the US is our prices for services are way too high. Covering a lot more Americans thru a government plan would force facilities and providers to get a lot more efficient.

Over the last six years I’ve done many a deep dive into the ACA’s shortcomings and why they exist; posts are here.

Bob Laszewski penned a very good piece on the plan here. Well worth a read.


Aug
14

Are health insurers profiting while providers suffer?

Well, yes – but it’s not intentional.

Most medical practices have seen a sharp drop in patient visits – and revenues – due to patient concern over COVID19 exposure. Hospitals have also suffered, as have ancillary providers, and many are on the brink of financial collapse.

Rural and safety-net providers are especially vulnerable, as many were on very shaky ground before COVID19.

Primary care providers are in the worst shape, as their patients often don’t have serious health needs that need to be addressed immediately. And primary care providers have the lowest pay as well. Research indicates that PCPs will lose about $15 billion this year.

Meanwhile, health insurers’ finances have never been better.

The connection is clear – insured people are not getting care, so insurers don’t have to pay their bills.

For months, healthcare providers have called on insurers to help them out by prepaying for care, paying billed charges, authorizing all treatment requests, providing loans, or otherwise funding providers. Much of this is nonsensical; authorizing all treatment requests would certainly lead to widespread abuse, over-treatment, and poor outcomes. Paying billed charges is nuts; NO ONE pays billed charges, which can be 10-30 times higher than average reimbursement.

What’s clear is COVID has likely created a significant one-time profit bump for healthplans, as a lot of foregone care will not be “made up” as practices gradually return to normal. While insurers should carefully assess their reserves, it is highly likely their “excess profits” won’t all be needed to pay for future COVID19 costs.

So, what to do?

Prepaying care may be a viable option. Healthplans would mine their data to determine what they paid a practice in the recent past, figure out how many members are using that practice, and sign a contract with the practice to ensure the plan’s interests are protected.

That’s just a short-term solution to a problem with roots that far predate the pandemic.

Reality is primary care is still under-valued, fee for service creates huge administrative friction and incentivizes over-treatment, and health care prices are unsustainably high.

What does this mean for you?

COVID will accelerate systemic changes that are desperately needed. There will be lots of pain for some stakeholders – primarily specialists and facilities.