Showing posts with label Affordable Care Act. Show all posts
Showing posts with label Affordable Care Act. Show all posts

Tuesday, July 12, 2016

President Obama Writes About Health Care Reform in JAMA

All aboard!
In a first for the Journal of the American Medical Association ("JAMA"), President Obama has authored a Special Communication on "United States Health Care Reform."

As the Population Health Blog would expect of any modern sitting President's essay on any political achievement, there are no new insights, no new useful lessons learned and no regrets. The reader is instead treated to an Affordable Care Act (ACA) legacy-building "bus tour" of selected facts and gratuitous framing of the Affordable Care Act (ACA). a

Briefly, Mr. Obama points out that, thanks to the ACA, the national uninsured rate dropped by 7% from 16% to 9%, which was accompanied by a 3.5% increase in the number of individuals with a personal physician and 2.4% increase in access to medicine. He takes credit for declines in the inflation rate for health care spending, decreases in consumer out-of-pocket health care spending, the rise of value based care, and improvements in quality of care.

The President goes on to putter around the edges with some suggestions for "building on progress to date":
He closes with "lessons for policymakers":
  • While change is difficult, "hyperpartisanship" makes it doubly so. The tools of hyperpartisan sabotage include "inadequate funding, opposition to routine technical corrections, excessive oversight, and relentless litigation."
  • Special interests "like the pharmaceutical industry" still "pose a continued obstacle to change."
  • The ACA is an example of American middle ground pragmatism between the extremes of vouchers for all and single payer. It should continue.
The PHB's Take

As years of over-lawyering has taught Americans (indeed, JAMA has put the academic credential "JD" after Barack Obama's name), real peer-reviewed policymaking benefits not only from the truth, but the whole truth.

What makes this JAMA piece less than the whole truth is failure to mention (other than in passing) how lingering of the Great Recession is what blunted the majority health care inflation, that a shocking amount of treasure as well as political capital was used for a seemingly modest 7% absolute reduction in the uninsured rate, that government sponsored plans will likely put the remaining regional insurers out of business, and that the prospect that any company doing business in the U.S. being legally compelled to share proprietary cost information is highly unlikely.

Oh, and by the way, short of firing up some more money-printing presses or some real reforms, Uncle Sam has no money to pay for any of the additional proposed suggested goodies.  There is no political appetite for shoveling any more federal money toward health care.  

Last but not least, the ACA was midwifed by a hyperpartisan ramrod that failed to get even one Republican vote in either chamber of Congress. This Special Communication does nothing to diminish that legacy.
Was this a squandered opportunity to set the record straight and address some meaningful reforms?

You be the judge.

But don't take the PHB's word it. Appearing in the same issue of JAMA is this editorial by the Brooking Institution's Stuart Butler.  He points out that Medicaid and not the marketplaces was responsible for a significant majority of newly insured Americans, that, even with premium support (or its expansion), commercial insurance enrollees are now saddled with very high out-of-pocket costs.

Oh, and then there is a consensus - now that the Recession is waning and the ACA is taking hold - that health care inflation is poised to accelerate.

Image from Wikipedia

(Updated July 14)

Posted by at No comments:
Labels: , , , ,

Thursday, April 7, 2016

A Presidential Politics-Free Health Wonk Review

Welcome to the Health Wonk Review, a compendium of the latest insights from more than two dozen health policy blogs. Each HWR issue is hosted at a different participant's blog, with topics that include health policy, delivery infrastructure, pharma, insurance and information technology.

Your HWR host, the Population Health Blog, uses a skeptical physician's perspective to write about "systems" of care.  Lately, it has focused on mHealth interventions that influence clinical and economic outcomes at a "population" level, as well as the effective governance of health enterprises.
 
It's also been a proud HWR participant for more than eight years.

The PHB is pleased that NONE of this issue's participants chose to mention any of the appalling lead candidates for U.S. President. Readers could use a break from the campaign cacophony, so the PHB welcomes you to the  Presidential Politics-Free Health Wonk Review.

The Affordable Care Act - What are the numbers?

Charles Gaba of ACASignups has been tracking the progress of the Affordable Care Act. This ongoing labor of love led him to comb through too-numerous-to-count public domain sources to provide an original-sourced summary (with links galore) of the health insurance status for the entire U.S. population in one chart.  He calls it "ambitious."  The PHB calls it gloriously detailed, credible and superb. KHN, you've met your match.

Medicaid

Hank Stern of the InsureBlog reminds us that Medicaid fails to meet the true definition of "health insurance." While beneficiaries get their health bills covered, this payment system is a government program that is ultimately paid for by taxpayers. As this form of income redistribution program expands, the opportunity for the "real" commercial insurance market dims. Ʀєfùsєηíκ indeed!

#mHealth - or the PHB is going to need an app to manage all its patients' apps.....

Peggy Salvatore of the Health System Ed Blog provides a summary of the ePharma Summit 2016 and regales readers with descriptions of how eHealth is helping persons who have gastrointestinal disorders, cancer or complex medication regimens be placed at the center of care.  "eHealth" is reaching critical mass without the help of any government mandates or meaningful use requirements. Imagine that.

David Harlow of the HealthBlawg takes a bite of Apple's CareKit Platform by unpacking the first app entrant from Iodine dubbed "Start."  Start promises to help users to individually manage both the benefits and side effects of anti-depressant medications. The app relies on a validated depression survey to assess progress, promising to take the guesswork out of treatment.

Outcomes

Brad Flansbaum of The Hospital Leader not only summarizes "the best (peer-reviewed) study on (hospital) readmissions to date," but interviews the lead author. As many have suspected, a significant proportion of preventable readmissions are outside the control of the institution and practically all of the current public-reporting measures fail to take that into account. Two insights are that 1) readmission rates will never go to zero, nor should they and 2) innovative interventions to minimize the risk of readmission are just now being developed. The PHB predicts that soon, no at-risk patient will leave the hospital without a dedicated app and telehealth-linked handheld device.  Given the dollars at stake, perhaps those patients without handhelds should be given one.....  

Pharma Misbehavior

Roy Poses from Health Care Renewal pulls aside the curtain and exposes the persons ultimately responsible for the OxyContin fiasco. Members of Purdue Pharmaceutical's C-suite had to pay hefty fines for the company's allegedly misleading advertising, but the upstream owners seem to have escaped scrutiny with their gazillions intact. If any of this is true, we've learned nothing about combatting corporate misdeeds.

Health Savings Accounts

Jay and Louise Norris of the Colorado Health Insurance Insider Blog take a look at some of the arcana and paranoia emerging around health savings accounts (HSAs).  First the arcana: HHS has a BPP about the HSA designation from QHPs that have otherwise been contrived to get around other regulations, likely promulgated in other BPPs. The paranoia is from wary conservatives, who are wondering if the liberals are unable to limit themselves to just "the nine words" by using BPPs to ultimately undermine HSAs.  What could possibly go wrong?  

Dual Eligibles

Tom Lynch of Worker's Comp Blog reviews the history of the successful Commonwealth Care Alliance.  This non-profit HMO currently serves over 17,000 "dual eligibles" in Massachusetts; these persons have significant disabilities and therefore qualify for both Medicare and Medicaid.  Despite huge claims costs, this HMO has been ably served by leadership who understands how money and mission underlie successful health insurance.

A Minimum Wage A Day Keeps the Doctor Away


Drugs: You Don't Get What You Don't Pay For

David Williams of the Health Business Blog has some thoughts for the pharmaceutical industry's efforts to justify its drug pricing policies. He recommends that pharma not only embrace cost-effectiveness, but lead the fight to include that methodology in all things healthcare.  They also need to help the public understand that you don't get good stuff for free: someone has to pay.

Speaking of Drugs....

Joe Paduda of the Managed Care Matters blog attended the Rx Drug Abuse Summit and has posted some of the more scary data that was presented there. The vast majority of heroin users started with prescription opioid drug abuse and a lot of smart concerned people are mobilizing to address the problem.  Awareness is the first step in addressing this unmitigated disaster.

Food, er Flu Fight

And saving the best for last, in the Health Affairs Blog, Peter Doshi, Kenneth Mandle and Forence Bourgeois scrutinize the CDC's recent recommendations on the treatment of influenza with antiviral drugs. After contrasting the recommendations with the FDA's and others' more detailed analyses on the subject, the authors find the CDC's promotion of a drug of questionable effectiveness to be "problematic."  In academic speak, them's fighting words. This ain't over, so sit back and enjoy while the flu fur flies.  

Your next Health Wonk Review will be hosted by the Health System Ed blog on April 21.


Posted by at 5 comments:
Labels: , , , , , , , , , , , , , ,

Wednesday, July 8, 2015

Three Downsides to Commercial Health Insurer Consolidation

Writing in The Wall Street Journal, Scott Gottlieb argues that the Aetna-Humana and the Anthem-Cigna combinations are evidence of waning insurer competition that is the direct result of Obamacare.  Not only are ACOs not a panacea, but the Affordable Care Act's insurance mandate to limit administrative costs is forcing Aetna et al to spread their costs over a larger base.  Dr. Gottlieb fears that the oligopolies won't be able to deliver on innovation and will limit consumer choice   

Too bad The WSJ didn't give him more print space.  If they did, Dr. Gottlieb may have also pointed to three other potential downsides to commercial insurer consolidation:

1) The concentration of risk: While having a small regional health insurer go bust is a big problem for hundreds of thousands of insurance enrollees, having a for-profit national insurer with tens of millions of enrollees go bust would be a national catastrophe. Think Lehman Brothers, Black Swans and Too Big To Fail.

2) Cronyism: Politicians and C-Suite executives no longer blush at the prevalence of the revolving door between government and all industry.  Health insurance will likewise be too regulated and complicated to leave to anyone other than insiders, who will naturally be unable to discern the line that separates their interests from the patients'.
 
3) Political Power: Will Washington DC and 50 states really be able to stand up to a handful of companies that dominate a fifth of the national economy?  Years ago, the commercial insurers remained silent while they were called "Fat Cats." The Population Health Blog bets that the next time a While House blames the insurers for rising costs, they won't remain so deferential.

Image from Wikipedia
Posted by at No comments:
Labels: , , , , , , , , ,

Wednesday, June 25, 2014

A Path Toward Further Health Reform Is Lined With the IRS?

As attention has shifted to phantom IRS emails, misbehaving Iraqis and our newfound national awareness of soccer's off-side rule, it's only natural for the Population Health Blog to wonder about the status of health reform.

Enter The New England Journal with a pair of perspectives on the coming prospects for the Affordable Care Act.

Over on the left, the Brooking Institution's Henry Aaron believes that, notwithstanding ascendant Republican hopes for the 2014 elections, Mr. Obama's veto power virtually guarantees the law's survival.  The only question is whether politics will get in the way of any adjustments.  Once we're into 2015 and beyond, these could include the mandate (weaken any penalties?), Medicaid (spending caps?), the states' roles (allow for local modifications?) and changing affordability standards (increasing income-based premium support for families).

Over on the right, the American Enterprise Institute's Joe Antos agrees there is no going back.  He offers up some potential conservative modifications for 2015 and beyond, such as shifting the insurance premium support to a defined contribution basis (versus a defined benefit), shielding mainstream health insurance by moving catastrophically ill persons to "high-risk" pools and requiring insurers (including Medicare) to leverage consumer education and incentives along with provider teaming to help steer beneficiaries toward lower-cost care options.

Drs. Aaron and Antos both agree that IRS-based enforcement rules may force significant changes.  Under current law, poor persons who underestimated future income for today's premium support calculations may be subject to claw-backs. According to Dr. Aaron, the IRS is responsible for administering that, and any payment would ultimately go to the insurer long after the fact.  Dr. Antos points out that the IRS's enforcement of the mandate could lead to the spectacle of tax refunds being withheld from low-income individuals and families.

The PHB is less sanguine.  While the PHB is no political pundit, the likely increase in the number of Republicans in Congress after 2013 combined with the kick-off of the 2016 Presidential race portends more of the same health reform gridlock. 

The only good news from Aaron and Antos is that growing antipathy toward the IRS may lead Congress to uncouple the IRS and it's enforcement mechanisms from the ACA. It may not be an example of pristine bipartisanship, but if it leads to necessary modifications of the ACA, that's not necessarily a bad thing.

Stay tuned!

Image from Wikipedia
Posted by at No comments:
Labels: , , , , , , , ,

Monday, March 10, 2014

The Concentration of Naiveté

The Population Health Blog's car garage is not the size of a football field. 

So, when the PHB spouse parks our car inside, she tends to err on the side of safety.  She pulls far forward so that the rear bumper doesn't get "dinged" by automatic closure of the garage door.  That obliges the Population Health Blog to inconveniently squeeze past and climb over the front bumper when it wants to use the PHBmobile.

The win-win fix to our travails arrived last Christmas when the perspicacious PHB gave the spouse a positionally adjustable ceiling-mounted laser. It blinks a ruby red light through the windshield onto the dashboard when the car is in optimum position.  Pull too far forward, and the beam will be directed on the floor or a front seat. 

Since it's been installed, the PHB spouse has ignored it.  The laser beam is effectively pointing at the back seat.

The good news is that the PHB's naiveté was limited to parking habits, one house's garage and a spend of $19. 

Not so for Ezekiel Emanuel's work in health reform in the White House and a spend of far more money. 

According to this article in this weekend's Wall Street Journal, the well-meaning Dr. Emmanuel couldn't change the habits of Medicare's vast bureaucracy or of Mr. Obama's formidable political advisors.  As a result, bundled payments remained the stuff of demonstration projects, while the closure of tax exclusions for employer sponsored health insurance was limited to "Cadillac" plans.

What's more, professional liability reform died in the crib thanks to the White House chief of staff Rahm Emanuel's unwillingness to stir the political pot:

He immediately cut me off: "Shut the f— up! We are not doing malpractice. Period. Every time the AMA comes in here, they don't talk about malpractice." Their first, second and third priority, he said, was the formula used by Medicare to determine doctors' pay. "We don't need to do malpractice for the doctors, and I am not alienating the president's base for nothing," he barked. "Stop it."

Rahm's reaction told me everything that I needed to know about the politics of the issue. Democrats would accept malpractice reform under two circumstances: if they needed it to keep the AMA's support for the bill, or if they needed it to attract Republican support. Neither was true. In backroom negotiations, the AMA was solely focused on securing higher physician payments—not on malpractice. And not a single Republican in Congress would even negotiate.

The president had already aggravated liberals by forgoing a "public option." He'd offended unions by limiting the tax exclusion. He wasn't going to antagonize trial lawyers, another core Democratic constituency, for no gain.(from the WSJ, March 7 "Inside the Making of Obamacare.")

In its own small way, the PHB called attention to the AMA's narrow-minded focus on the SGR five years ago.  But the AMA's blunder and PHB's prescience are not the point.  Or, rather, points:

1. The health reform that eventually passed was a curious mix of White House naiveté and Washington inside-the-beltway politics. The result was the Affordable Care Act which continues to spawn quick-fix delays and throw sand in the gears of government.  We deserved better.

2. By concentrating risky decision making in Washington DC, the upside gains in big government may be undercut by the downside of unintended consequences and half-baked decision-making in all 50 states.  It's scary to think that the likes of Dr. Emanuel had such power.

Lessons learned.
Posted by at No comments:
Labels: , , , , , ,

Tuesday, December 17, 2013

The Looming Credibility Trap of Obamacare?

While the young Disease Management Care Blog was first introduced to the concept of the "credibility gap" by Lyndon Johnson's Vietnam war, it wasn't until it started paying attention to blogs that it ran across the term "credibility trap." The former describes a disbelieving citizenry, while the latter describes a disbelieving government.

Enter this telling PolitcoMagazine article on the travails of being a Washington DC Cabinet Secretary.

In the modern course of our Republic, there are 23 talented overachievers who nominally preside over a huge federal bureaucracy. The DMCB thinks of that as the core machinery that lies at the heart of the liberal promise that Big 21st Century Government Can Accomplish Great Things.

If the Politico article is correct, successive White House Administrations have marginalized the Secretaries, letting the majority of Washington DC run like some side-show perpetual motion machine. As the DMCB understands it, that leaves the White House to insource the management of the really important stuff, like getting reelected or reversing rising ocean levels.

And so it was when it came to the implementation of the Affordable Care Act. Looking past the partisan cacophony, it appears the White House genuinely counted on HHS to smoothly implement the health care marketplace and its various mandates. What happened was a fumble of historic proportions that will continue in the weeks and months to come.

While conservative pundits are using the Obamacare imbroglio as another tiresome I-told-you-so lesson in government overreach, the DMCB is worried that the bright men and women who are responsible for implementing health reform are getting a crash course in the cynicism of the credibility trap.

Statutory deadlines are now meaningless. Regulations can be ignored. Being "on message" trumps the truth. Czars go into private equity so that lobbyists can become insiders. Political expediency is allowed to batter markets. Blowback begets stopgap crisis management by an insular political elite.

And as 2014 is threatened by death spirals, corrupted commercial enrollment data, unpleasant out-of-pocket surprises for consumers, small as well as large business market rate shocks, unpredictable legal challenges and further mischief by an emboldened Republican opposition, it becomes less a function of whose "fault" it is and more of a dreary exercise in keeping the Amtrak of health care from running off the rails.

The folks running the government bureaucracy are stuck with this lemon. Many are probably thinking that they deserve better.

Is the DMCB reading too much into the symptoms of C.T?

You be the judge.
Posted by at No comments:
Labels: , , , , , ,

Monday, November 18, 2013

Stuff Their Mouths with Gold

The Disease Management Care Blog uncovered this confidential memo, presumably authored by a health insurance CEO to the company's senior management team. Any resemblance to reality or perception is purely intentional.

DATE: November 18, 2013

TO: Senior Management

FROM: The Office of the CEO

RE: Our recent White House meeting on the individual mandate

As many of you are aware, I and other commercial insurance CEOs visited White House to barnstorm over ways to help President Obama out of his latest political pickle.  While, like you, I was caught off-guard by the President's "I hear you loud and clear" proclamation, our trade association CEO, Karen Ignagni, was once again masterful in helping us understand the big picture.  I wish to share that information with you.

1. Remember that the Affordable Care Act (ACA) is a commercial insurance gold-laying goose. Millions of Americans are being forced to buy our products, and a lot of them will be subsidized by the faith and credit of the Federal government. While the President will use every opportunity to deflect any blame on us, we must remember: eye on the prize, people!

2. While we would naturally prefer that, effective January 1 2014, our customers move from the skimpy lower margin individual plans to the richer and more profitable "essential health benefit" plans, Ms. Ignagni anticipated that the amateurs advising the President would lead to him to having to make stuff up on the fly.  Think of this as the price of doing business.
 
3. While many of you will be working long hours through the upcoming holidays to un-disenroll the hundreds of thousands of insureds that got our cancellation nastygrams, let me assure you that getting it right most, not all of the time is our new business mantra.  Sure, thousands of persons will allege that that they thought they were covered with X deductible for Y condition, but we can clean that up after the fact through the standard appeal process.  Hey, it's right there on the White House web site.

4. It's no accident that Ms. Ignagni described our White House meeting as "very productive."  While the details cannot be shared with you, as many of you know, the ACA allows for certain "risk corridor offsets" to be made if there are early death spirals in the mandated minimum benefit plans.  While opponents of the ACA will attempt to undermine those costly offsets in the upcoming government budget battles, we're hopeful that politicians on both sides of the aisle will ultimately recognize that it's not our fault that the White House's insights on health insurance is about as deep as Toronto Mayor Rob Ford's awareness of the perils of crack.

5. We must remain quiet and outside the public eye. While all of us are appalled at the Administration's blunders, the last thing we want to do is to remind our Democratic allies about the "public option."  If we are approached by the media, let's recall that Aneurin Bevan, the founder of the National Health Service, neutralized the opposition of Britain's doctors by "stuff[ing] their mouths with gold." The ACA is our gold and let's keep our dismay out of sight and our mouths silent. 
Posted by at No comments:
Labels: , , ,

Monday, October 21, 2013

The High Price of High Deductible Plans and the Potential Role of Population Health Management

Your bronze plan ticket to health care?
Should patients be forced to reach a spending threshold before their insurance kicks in? At first glance, it makes sense, because health consumers' "skin in the game" forces them to think twice before going to the emergency room for a sore throat, or an orthopedic surgeon for simple back pain.

Wharam and colleagues examine the science behind high deductible insurance in this just-written article in the New England Journal.

And the science says there is a lot we do not know.

Once insurance risk is monetized into premiums, policymakers as well as insurers are operating in the dark about calculating the right deduction for a given income level. One example is Cover Oregon's $5000 deductible for persons who are at 200% to 400% of the federal poverty level. That means a family with a yearly income as low as $47,000 would have to spend more than 10% of their income on health care before seeing a dime of insurance coverage.

"Egads," says the DMCB.

Given that stark reality, the challenge is to figure out how an up-front deductible influences "buying behavior" once persons get sick. Unfortunately, most of the research out there is on the impact of relatively "small" amounts of out-of-pocket expenses on health care utilization, especially in low-income populations. The bad news is that lay-persons - who are unable to discern the difference between a simple headache vs. a brain tumor - tend to "indiscriminately" lower all utilization as their cost sharing goes up.

There has also been no research on the impact of high deductible plans on mortality or chronic condition control.

Concluding that the U.S. is "poorly prepared" for what will happen under Obamacare's bronze high deductible plans, Wharam et al recommend there be more research on the topic.  Pending that, they suggest consumers be educated about their insurance purchases and be encouraged to chose low-deductible plans. They note that the star-crossed insurance exchanges (once they're fixed) can be configured to help do that. When there is employer-based insurance, employers could be encouraged to make the deductibles more proportional to income. In addition, health savings accounts could also help.

While the authors don't use the words "population health management," they tap this discipline as one solution to this Obamacare problem. They point out that predictive modeling/risk stratification can be used to create "personalized" insurance designs that optimize high-risk patients' access to care. Patients in these plans could have access to decision-aids and coaching that help them figure out when it's a simple headache and then they should seek medical care.
Posted by at No comments:
Labels: , , , ,

Wednesday, October 2, 2013

Valuable Personal, Political and Health Reform Lessons, Courtesy of the Federal Government Shutdown

Coming to consensus
the old fashioned way
The Disease Management Care Blog views the federal government shutdown with the same morbid fascination of watching personal injury lawyers justify their double digit malpractice suit contingency fees: it's so awful, it's hard to look away.

The good news is that that doesn't mean that the shutdown doesn't hold some important personal and political lessons.  They can make DMCB readers better citizens and our political class a credit to our Republic. 

To wit......

When the DMCB spouse expresses consternation over the boneheaded actions of her husband, the DMCB can now respond by:

1. changing the subject,
2. retreating to the DMCB World Headquarters and blogging about the spouse's unreasonableness,
3. referring to the alleged lapse as a "glitch."

Things don't go well in the opening day of a widely anticipated unveiling of the largest health care achievement in the history of the United States.  If you were in charge, you would respond to the health insurance exchange breakdown by:

1. recognizing the problem and promising to fix it,
2. reminding the public about the painful gap between lofty campaign promises and disappointing bureaucratic reality,
3. shrewdly drawing flattering comparisons to Apple, the most widely admired brand in the world.

As the leader of a political coalition, you are stymied by the division of powers in the world's longest lasting democracy.  In response you:

1. seek consensus
2. deploy ad hominem attacks in press conferences
3. offer to compromise by allowing the opposition to do things your way.

Wanting to be an informed member of the electorate, you regularly watch either CNN, FOX News, MSNBC, PBS, CBS, NBC or ABC because:

1. These broadcasts' news editors subtly frame their closed information loops to meet your own political biases,
2. You haven't discovered BBC or Al Jazeera
3. There aren't any movies on TV featuring svelte vixen vampire babes having their way with their mesmerized male victims.

By pointing out that Obamacare is "the law of the land," you are really saying:

1. Our representative democracy passed legislation that was signed by the President and upheld by the Supreme Court, so get over it,
2. Now wait a minute, our representative democracy can modify or even roll back health care laws.
3. Enough with the debate, time to move on and figure out how to make preschool education, low interest mortgages and low-fat frozen yogurt protected federal entitlements.

Being a Game of Thrones fan, you wonder if the following might not be useful in settling the budget impasse:

1. Asking what the honorable Ned Stark would do, until you recall that he was beheaded.
2. Invite the opposition to a Red Wedding
3. Call up your elected representative and say "Hodor!"
4. Call up your elected representative and hear him or her say "Hodor!"
Posted by at No comments:
Labels: , , , , , , , ,

Monday, September 30, 2013

Everything You Need to Know About Health Care Reform, Thanks to a 25 Minute Video, Courtesy of Managed Care Magazine

Thanks to Managed Care Magazine, the Disease Management Care Blog can post this interesting 25 minute interview with Princeton healthcare economist Uwe Reindardt.  Suitable for desk-bound meal-break viewing by overachieving DMCB readers, the modest and insightful Dr. Reindardt gets it mostly right:

No, the slowdown in the U.S. rate of health care costs cannot be ascribed to passage of the Affordable Care Act.  It started wayyyy before Obamacare was passed and is more likely due to the economic slowdown and increased consumer cost-sharing.

Accountable Care Organizations remain an "iffy" experimental proposition because they "don't go all the way like Kaiser."

Republican proposals to let health insurers sell their products across state lines are hardly a health reform panacea, because prices (and therefore premiums) are not a function of where the insurer is domiciled, but where the care is rendered.  Texas insurers would still have to pay New York prices.

Americans use fewer pills, occupy less bed-days and see fewer doctors, but we pay more because providers can charge more.  Despite being relatively small vs. the behemoths like Aetna and Cigna, regional hospitals have considerable market power that translates into take-it-or-leave it local single seller monopsonies.   Europeans, in contrast, have lower prices because their system is dominated by single purchaser monopolies.

We're headed toward a three-tier system comprised of 1) the indigent safety-net public programs, 2) the middle class "reference pricing" "networks" where consumers pay the difference if they want to buy up and 3) "boutique" health care for the 5%.

There's reason to be optimistic about the next five years thanks to a sluggish labor market (making it easier to impose networks and even more cost sharing) and innovation (computational capacity is putting meaningful quality measurement within reach, while techy gizmos are making self-care simultaneously cheap and fun). 

Plus, there's reason to be of good cheer.  Compared to the U.S. education and the legal systems, health care is far more efficient and consumer-friendly.  Stop beating up on yourselves.

(The DMCB didn't quite agree with Dr. Reinhardt's views on worksite wellness.  He finds the notion counterintuitive and intrusive, preferring that insurers own wellness.  He neglects to mention that the employers who invest heavily in wellness are typically self-insured and that employers have an arguable stake in improving the quality of their human capital.)



Posted by at No comments:
Labels: , , , , , , , , ,

Tuesday, September 10, 2013

How Badly Obamacare Beat Up On the Health Insurers, and What Does It Mean for the Individual Market

D.C. deals with health insurers
As Disease Management Care Blog readers are aware (for example, here and here), Obamacare forces health insurers to spend at least 80% (small group) to 85% (large group) of their premium income on health care, leaving only 15% for "other," including administrative overhead and profits. If that 80%-85% "medical loss ratio" (MLR) threshold is not met, insurers have to rebate the difference to their customers.

 While the White House has been happy to extoll the millions of dollars that were repaid to consumers (even though the individual checks were hardly eye-popping and then there is the risk that they're taxable), the DMCB is interested in what actually happened to the commercial insurers.  Did they game the system and garner even higher profits?  Or, have they gotten their comeuppance, are now losing money and have to pursue other lines of business, like covering zombie attacks?

This article in the latest Health Affairs looked at that impact of the law when it went into effect on January 1, 2011.  The authors used NAIC data to examine the impact on the individual (N=1,219), small group (N=804) and large group market (N=750) insurers.

Individual, small group and large group numbers are broken out below. If there is a *, the change is statistically significant.

In the individual market, from 2010 to 2011:

Median medical expenses, as a percent of premium, increased      by 5.5%*.
Administrative expenses, as a percent of premium, decreased            by 2.6%*.
Profit (otherwise known as "operating margin" or the bottom line) decreased by 1.3%*. "For profit" insurers fared even worse, with a decline in operating margin of 2.2%* vs. their nonprofit competition with a decline in 0.8%.

2011 operating margins were overall negative:

Individual overall -0.1%.
Nonprofits:  -3.5%.
For profits:  0.4%.

In the small group market:

Median medical expenses increased by 0.7%.
Median administrative expenses declined by 1%*.
The bottom line increased by .5%. Nonprofits saw an increase of 1.2%* vs. the for profits having a small decline of .3%.

2011 operating margins were positive, ranging from 2.8% to 3.8%  across the non and for profits, respectively.

In the large group market:
Median medical expenses declined by 0.7%.
Median administrative expenses declined by 0.9%%*.
Profit increased by .7%*. Nonprofits saw an increase of 0.1%* vs. the for profits having a increase of 1.2%.

2011 operating margins were positive, ranging from .7% to 2.6%  across the non and for profits, respectively.

The DMCB's take:

Obamacare had a single digit impact on health insurers.  More was spent on health care and less was spent on administrative costs.  While the shifts were relatively small, those changes represent swings of hundreds of millions of dollars to the bottom line in an already thin margin business. If the purpose of Affordable Care Act was to beat up on the health insurers, it was more of a push than a shove.

Small and large group profitability increased and operating margins were positive, while the individual market struggled. As readers may recall, the inability of individuals to obtain coverage at any price was a big factor in the eventual passage of the Affordable care Act. While the future individual market may eventually benefit from an influx of healthy young "invincibles" armed with an accompanying bolus of insurance subsidies, Obamacare ironically hurt the individual market in 2011. If health care utilization didn't go down in 2011 as a result of the economy, it could have been a lot worse.

That tells the DMCB that, contrary to the insurers' reports of doom and gloom, the 80%-85% MLR rule hasn't been a catastrophe.  On the other hand, it hasn't been good news for the individual market.  If the young invincibles don't 1) respond to the individual mandate, 2) use functioning insurance exchanges and 3) sign up, it could portend further stress on that sector of the health care economy.  No wonder the Obama Administration is pushing that so hard.
Posted by at No comments:
Labels: , , , , , , , ,

Thursday, August 8, 2013

Insights on Delaying Obamacare's Employer Mandate: Four Potential Unintended Consequences?

Which is it?
Look at we did!

Delaying the employer mandate for one year is simply more evidence of Obamacare's unworkable complexity, says detractors.

The delay is flexibility and democracy in action, says supporters. 

The Disease Management Care Blog is troubled by how Congress and the Obama administration underestimated the complexity of the local implementation of a one-size-fits-all national health program.  It also knows that the White House needs some Affordable Care Act (ACA's) elbow room.

To gain a better understand what's going on, check out this article appearing in the New England Journal. 

Recall that the intent of the ACA was to preserve employer-based insurance while enabling individuals to access similar levels of coverage in on-line exchanges. Toss in some income-based subsidies on the upside along with IRS penalties on the downside, and the intended outcome is that millions of Americans will enter the national risk pools. That, in turn, should lead to premium drops and greater access to health care.

So what could be the impact of the delay?

First off, there's what won't happen. The authors estimate that 2014 will be business-as usual for the vast majority of persons with employer-based insurance.

But here's four things that could happen:

1. Approximately 5 million part-time workers may be closed out from access to their employer's insurance for another year. In addition, the $10 billion in government income from the $2000-per-worker) will be lost.  Both these numbers are small potatoes in a trillion-dollar enterprise involving tens of millions of workers, unless, of course, you happen to be one of those workers.

2. Millions of employed full time workers will continue to take a pass on taking the paycheck deduction for their employer-based insurance.  Whether they change their mind in 2014 will not depend on how hard their employers work to sign them up, but how aggressively the IRS pursues the individual mandate. 

3. Attached to the employer mandate were regulations that would have forced employers with a workforce of greater than 50 persons to offer competitive (read "low") insurance premiums.  Since that's also been delayed, employers and their employees who want insurance have an even greater incentive to access the on-line individual exchanges.  Employers get to reduce their insurance costs while individuals get to take advantage of those upside subsidies. The employer-employee win-win arrangement could not only undercut employer-based insurance, but "triple" the Fed's subsidy budget.

4. The DMCB's physician colleagues are not immune either.  There is emerging evidence that the individual exchanges are likely to offer "frugal" insurance plans.  Early indications are that these plans will turn to the old tricks of restricted networks and low provider reimbursement levels. This could result in millions of newly insured persons further stressing an overloaded primary care provider network.

Posted by at No comments:
Labels: , , , ,

Tuesday, May 14, 2013

The Politicizing of Preventive Health Care: Whither the US Preventive Health Services Task Force?

Here comes the camel nose!
Kudos to JAMA for tackling what the Disease Management Care Blog has been saying for years: now that the Washington DC's camel nose is under the tent, there is no way health insurance coverage - and the care it pays for - isn't going to become politicized.

That's the bigger issue in this just-published article by Steven Wolf and Doug Campos-Outcalt. They're focusing on the political pressure that is being brought to bear on US Preventive Services Task Force (USPSTF). As readers may recall, the Affordable Care Act requires health insurers to fully cover screening services that are deemed effective by the USPSTF. Drs. Wolf and Campos-Outcalt point out that politics rudely intruded on the USPSTF's determination that the evidence supporting mammography for women under age 50 years was lacking. The resulting firestorm not only prompted Congress to not only waive the USPHSTF recommendation, but led some of its members to question the Task Force's integrity.

As academics writing in peer-reviewed journals are wont to do, the authors suggest that this can be remedied by another layer of bureaucracy. They want a new "firewall" committee to be inserted between the "pure" evidence-based USPHSTF and the "political" fisticuffs of the public square.  It'd be the job of this a new entity to insulate USPHSTF by reconciling the proof and the politics prior to the upload of the final recommendations to the mandarins that are running CMS.

"Another committee?" asks the dismayed DMCB. While that would end the Obamacare fiction that health reform was ever going to be truly "based on science," the real Achilles heel of the JAMA proposal is that it literally doubles the opportunity for political meddling. The smartest political operatives will see this as a target-rich environment and naturally seek to influence all of the committees with any jurisdiction over the medical-industrial complex of laboratory medicine, radiological imaging and medical devices.

The DMCB has bad news for its colleagues who thought that they could have the Washington DC "cake" of enlightened government involvement along with the "icing" of scientific independence. Uncle Sam's been given a clinical inch and now he'll take a political mile to influence clinical guidelines and define standards of care with a one-size-fits-all mentality sprinkled with a healthy dose of cronyism.  Surprise!

The DMCB has an alternative solution: CMS should tread very carefully when it comes to insurance design.  Congress needs to reengineer the preventive health part of the ACA. Instead of building new infrastructure to make up for the emerging failures of the old infrastructure, Washington should be pushing benefit design down, not up, to the local level. It can partner with commercial health insurers to assure that the USPSTF recommendations are considered, but with local committee assessments of market demand, provider opinion and community input to determine what's best for its covered population. It should do this while simultaneously promoting the use of shared decision making to help every patient ponder for themselves when testing is in their best interest.
 
Let a thousand flowers bloom.

Image from Wikipedia
Posted by at No comments:
Labels: , , , , , , ,

Tuesday, May 7, 2013

The Oregon Medicaid Experiment: Good Study, Bad Politics

Examining the Oregon Medicaid Study
By now, most Disease Management Care Blog readers have probably read or heard about the release of the health and costs outcomes data from the Oregon Medicaid experiment. The purpose of the study was to ascertain whether one of the arguments still being used to support the Affordable Care Act is really true, i.e. that health insurance leads to better health leads to lower health care costs.

It's not a minor argument. When the important provisions of the ACA go "live" in 2014, liberal-progressive supporters of the ACA will be tenaciously seeking to validate the merits of health care reform, while conservative critics will be looking for any excuse to strangle Obamacare in its crib.

So naturally, if a well performed study supported or contradicted the health insurance hypothesis, it would make little political difference.

How was the study done?

Unable to afford universal enrollment of approximately 30,000 eligible persons into Medicaid, Oregon figured the only fair way to administer the program was to have a lottery. Because participating individuals were allocated to one of two options (with or without Medicaid) by chance, Oregon's approach had all the makings of a prospective randomized clinical trial.

The lottery was conducted in 2008 and the health status and health care costs for the winners and losers were compared using face-to-face interviews an average of 25 months later. While the lottery was state-wide, the study itself was limited to the Portland area. The researchers planned to compare the health status of 10,405 individuals who had won the lottery to 10,340 individuals who had lost and were not enrolled in Medicaid.

Not all persons signed up for Medicaid and others couldn't be tracked down for the one-on-one interviews, leaving a final number of 6487 (62% of the eligible) lottery "winners" versus 5842 (57% of the eligible) "losers."

What were the results?

All in all, the results were disappointing for persons believing the health insurance hypothesis. Having Medicaid didn't lead to better control of high blood pressure, diabetes, blood cholesterol levels or overall cardiac risk. There was also no impact on the likelihood of being admitted to a hospital or having to go to an emergency room.

The good news was that having Medicaid seemed to lessen the likelihood of battling untreated clinical depression and, if pap smears and prostate specific antigen tests are markers for access to primary care services, Medicaid increased that also. Last but not least, Medicaid participants were less likely to have catastrophic medical expenses or be in debt to cover medical bills.

Was the study perfect?

Nope. The study's generalizability was limited by being restricted to persons age 19-65 years in Medicaid and in an urban environment. Two years may not be long enough to truly gauge the benefits of having insurance. Many persons were lost to follow-up. Statistics limited the ability of the researchers to spot smaller improvements in health status.

And how did supporters and detractors of Obamacare react?

As expected. If bloggers are a window into the soul of the body politic, this KHN article amply demonstrates that no one's mind has been changed. Between inflating or minimizing the study's imperfections, cherry picking the outcomes and spinning them, we are no closer to achieving any consensus.

The Disease Management Care Blog's take:

Studies like the Oregon Medicaid study are not only rare, they're as good as we're going to get. Since no study is perfect, the likelihood that Washington DC will be able to use any nuanced research insights to inform the next steps in pursuit of the Triple Aim is not good.

The battle lines have hardened.
Posted by at No comments:
Labels: , , ,

Wednesday, March 20, 2013

Exorcising the Ghost of Cost Shifting: Why the Alternative May Be Worse

The cost-shifting ghost!
The Disease Management Care Blog continues to welcome blog posts from outside authors. This is another one, courtesy of Erik Tollefson, who works in the health policy field. He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

Of all the mythologies in the arcane world of health economics, cost shifting holds a hallowed place. First conjured up by commercial insurers in the 1970s to warn against catastrophic Medicaid cuts on hospitals’ financial positions, the rhetorical phantasm of cost shifting continues to rise from the dead to haunt the public sphere, particularly when politicians propose to reform public insurance reimbursement levels or undertake large-scale reforms.

The theory of cost shifting is fairly straight forward: hospitals raise prices on private insurance customers when public payments are cut in order to make up for lost revenue. For all the importance afforded to cost shifting, however, there still remains a (highly) inconvenient truth: Numerous academic studies over the past 20 years have failed to find systematic evidence of its existence.

A recent National Bureau of Economic Research paper by Dranove, Garthwaite, and Ody examines the phenomenon of cost shifting in a new light. While scholars traditionally have examined hospitals’ pricing responses to planned changes in Medicare and Medicaid reimbursement levels, the financial crisis of 2007 provided a unique opportunity to analyze how they responded to a one-time loss in wealth. That crisis had a substantive impact on most hospitals; Not only did consumer demand for services decline, but many hospitals lost a substantial portion of their endowments due to the ensuing market turmoil. Dranove and his co-authors wanted to explore if hospitals that lost a significant proportion of their endowment would “cost shift” in order to make up for lost wealth, compared to hospitals that did not suffer similar losses.

What the authors found was disconcerting. Only a small sample of hospitals raised prices in the aftermath of the crisis. Many more responded with another strategy: cutting costs. Hospitals axed planned and ongoing capital expenditure projects (e.g.,  electronic health records) and shut down low-profit centers, including resource-intensive trauma and psychiatric centers.

Although the paper’s results cannot necessarily be generalized to all health care markets, it does suggest that hospitals can and will respond to financial downturns by cutting vital services.
 
Since the concept of cost shifting offends widely held notions of fairness, the further subsidization of baby boomers’ Medicare benefits in the purported era of austerity might not be politically palatable. The paper by Dranove et al, however, shows that a far worse scenario is possible if Medicare payment rates are slashed: cuts to costly but high value clinical programs. That’s ironic, because many of the benefits ascribed to the Affordable Care Act were predicated on increasing access to crucial medical services, particularly in underserved areas.

The only good news is that if hospitals react to changes in reimbursement levels and wealth loss by cutting important services, policy makers will be unable to summon forth the spirit of cost shifting.  While skeptical economists everywhere may rejoice, that will be small comfort to communities that find that their local hospitals are cutting basic services.
Posted by at 2 comments:
Labels: , ,

Wednesday, February 6, 2013

The Sunshine Act Will Cost Pharma and Medical Device Manufacturers Hundreds of Millions of Dollars

The regulators go to work....
Fed up by pharmceutical, biotech and medical device manufacturers' vulgar use of "honoraria," "consulting fees" cozy "investment" relationships and other financial sweeteners to buy physician loyalty, Congress included the "Physician Payment Sunshine Act" as part of the Affordable Care Act.

The initial proposed set of regulations appeared in the Federal Register on December 19, 2011.  Comments were invited and CMS' reponse i.e., the"Final Rule," has just been released.  It can be found here.  This sample of the mainsteam news media reporting indicates generally positive reviews.

Case closed? 

Not quite.  That's why you read the Disease Management Care Blog.

As the DMCB understands it, the idea is to notify patients and the public about potential physician conflicts of interest, especially if they are recommending one treatment versus another. The financial relationship data from August through December of this year has to be reported to CMS by March 31, 2014. CMS will, in turn, post the information on the web in September of 2014.

While the DMCB agrees with the intent, it also took the time to scroll through the Final Rule and found some interesting information on page 226. 

CMS estimates the manufacturers will each need to hire a compliance officer and bookkeeping personnel.  Based on prevailing hourly salary rates (page 228) for approximately 1,150 companies, the total cost in year 1 of the Sunshine Program will be $193,037,104.  After some systems automation kicks in and start-up costs are eliminated, the cost will decrease to $144,777,828 "annually thereafter" (p. 229).  There will also be "infrastructure costs" to the tune of just over $12 million in year one and just over $1 million for each subsequent year.

The DMCB thinks that's worthy of some sticker shock, especially when we're all agreeing that the health care system is already too expensive. Ultimately, it remains to be seen if patients will use the internet as advocate-consumers and blunt their physicians' conflicts of interest.  Based on data like these (the impact on consumer behavior) and these (on hospitals) we don't know if patients will vote with their feet or if physicians' bad behavior will lessen. 

It could work, but once again, finding out is going to cost American health care consumers hundreds of millions of dollars.

Stay tuned!
Posted by at No comments:
Labels: , , , ,

Wednesday, January 30, 2013

Can Our Politicians (or the Market) Improve on NICE?

The Disease Management Care Blog continues to welcome blog posts from outside authors.  This one is courtesy of Erik Tollefson, who works in the health policy field.  He can be reached at erikDOTmDOTtollefsonATgmailDOTcom.

In the halcyon dog days of summer 2009, U.S. politicians aimed their rhetorical fire on a rather odd target: the UK’s National Health Service (NHS).  With a vote on President Obama’s proposed health reform on the horizon, politicians hoped to tar the reform effort by association: The NHS was painted as inefficient; a decried relic of “socialized medicine” and state planning; some damning charges were levied against NICE (The National Institute for Clinical Excellence) as the putative “death panel” rationing potential life-saving treatments to patients.

In a strange turn of events, recent developments in implementing the ACA, particularly the legislative appropriation of basic benefits, may show the limits of the US political system in making important decisions for patients in an economically efficient matter.
 
Two recent examples may raise red flags.  ACA’s “Basic Benefit” program, originally conceptualized as a way for the federal government to standardize benefit programs offered on health care exchanges, was devolved to the states in order to dispel concerns over excessive bureaucratic intervention in the process. 

The result: massive lobbying by medical interest groups, including chiropractors and acupuncturists, to include their services in the benefit package without examination of medical evidence or economic value of their use. While these rent-seeking activities were seen as part and parcel of the political process, the Nebraska basic benefits proposal to offer a high-deductible plan did not pass muster. 

One economic case for the ACA (albeit a limited one) was predicated on leveraging efficiencies in drug prescriptions for generic drugs, particularly biosimilars.  Recent reports indicate, however, that biotechnology companies are trying to put additional roadblocks in the process to prescribe biosimilars, perhaps preventing the anticipated competition and forecast savings.
 
Although these are only a few examples, they have rapidly emerged as both the federal and (some) state governments have started to implement ACA provisions. 

Regardless of the political histrionics surrounding “socialized medicine”, the ACA is now (for better or worse) the law of the land. The issue of whether “rationing” exists in any health care system is a red herring; in a world of scarce resources, rationing is performed regardless of political ideology.

The real question is: how will rationing ultimately be conducted- out in the open as part of a rigorous deliberative process, or behind closed doors by legislative fiat?  In this sense, the US politicians’ attack on NICE was both prescient and half-correct:   the ACA would indeed give new power to legislators and bureaucrats to make decisions on the clinical and economic efficiency of medical treatments for patients, and NICE is the (sometimes unpopular) face of those rationing decisions.
 
At the end of the day, however, the implementation of the ACA raises seminal new questions about whether the business of politics can be separated from the dispassionate analysis needed to evaluate clinical treatments.  NICE is far from perfect: the institution has received withering criticism for tough decisions and a less than perfect methodology (e.g., the QALY).  One of the main challenges for US politicians, or the healthcare market, is whether they can come up with a better system. 
Posted by at No comments:
Labels: ,

Tuesday, January 8, 2013

Seven Things You Need to Know About 2011 Health Care Spending

If you're interested in learning more about the latest U.S. health care cost trends, everything you need to know is in this article in the January 2013 issue of Health Affairs.

Or you could rely on the Disease Management Care Blog to point out the article's 7 most important points.  Use them to impress your colleagues and stymie your foes:

1) The data only go up to 2011; we'll have to wait another year before we'll know about 2012.

2) 2011 health care spending, as a percent of gross domestic product, remained at 17.9%.  The overall economy was slow and that took its toll on the health care sector.

3) That comes out to $2.7 trillion or $8,680 in health care spending per person.

4) While the percent remained stable, the economy experienced modest growth in 2011. The health care sector, thanks to an overall growth rate of 3.9%, kept pace. Prices for services grew less than the demand for services.  As we grow older, demand is likely to grow.

5) Medicare and private insurance grew faster than the economy, which was offset by Medicaid cost cutting by the states.

6) If the past is any guide, when the U. S. economy rebounds, health care spending is likely to accelerate and resume its march toward becoming 20% of GDP.

7) The relative stabilization of 2011 health care costs is independent of the Affordable Care Act.  Many of its important provisions (such as the mandate) don't kick in until 2014.
Posted by at No comments:
Labels: , , , ,

Wednesday, January 2, 2013

Medicaid Disease Management: No Impact on Emergency Room Utilization or Inpatient Costs for Enrollees with Diabetes?

Regular readers of the Disease Management Care Blog know that Medicaid is coming. While many of the nation's Governors have declined President Obama's invitation to run Medicaid the Affordable Care Act way, others have agreed to use the ACA's generous funding to enroll millions of their indigent citizens into this vastly expanded public insurance program.

"No problem!" says the disease management vendors.  For years, they've been offering their services to state Medicaid programs and would be happy to expand their contracts.

Unfortunately, an article by Matthew Conti that was just published in the journal Health Services Research suggests that that may not be a good idea.  The article's title is Effect of Medicaid Disease Management Programs on Emergency Admissions and Inpatient Costs.  The only thing that's missing are the words "The Lack of Any" at the front of that sentence.
   
The article studied the impact of diabetes "opt-out" disease management on diabetic patients' emergency room utilization and admissions in three states' Medicaid programs: Washington (started in 2002), Texas (started in 2004), and Georgia (started in 2005).

These states with were compared to states without diabetes disease management.  These control states were selected on the basis of baseline Medicaid enrollment trends that were similar to the three study states. These control states were Hawaii, Kentucky, Massachusetts, Maryland, Maine, North Carolina, Nebraska, South Carolina and Tennessee.

To perform the comparison, Dr. Conti used the Agency for Health Care Research and Quality's (AHRQ) National InPatient Sample (NIS) from the Health Care Cost and Utilization Project ("HCUP"). These databases contain patient-level and longitudinal hospital information on inpatient stays, including cost, payer, admission type (e.g., emergency, urgent and elective), age, gender, primary payer, and total charges. The span of data that was used went from 2000 through 2008.

A complicated pre-post "difference in differences" model was used to compare baseline vs. follow-up:

1) total inpatient charges/Medicaid enrollment (which averaged $430 per diabetic enrollee, with a 95% confidence interval of $265 to $700) and

2) emergency admissions/inpatient admissions (a ratio of 0.37 per admission with a standard deviation of plus or minus 0.12)  All Medicaid enrollees with diabetes were included in the analysis, whether or not they had been enrolled or opted out.  The author used this approach figuring that if a statewide disease management program enrolled up to a third of eligible persons with diabetes (that was the case in Texas), there should have been an observable impact on the entire population. That's the approach favored by the Disease Management Purchasing Consortium.
 
The results?  No state with disease management had lower emergency room utilization or inpatient costs for their Medicaid enrollees with diabetes. The DMCB couldn't find a table with numbers, but the figures (which can't be reproduced without permission) show little impact over time.

What can readers conclude?  Assuming that, during the period of study, the three states' Medicaid programs suffered from the program's endemic issues of underpayment to providers with a relative lack of access to primary care:

1. "Blanket" call-everyone telephonic disease management cannot make up for fee-for-service Medicaid's shortfalls.  It remains to be seen if the ACA's revitalization of Medicaid will make up for this and increase the parallel impact of disease management. 

2) This also means that Medicaid's experience with disease management can't be generalized to other types of insurance with better provider payment rates and patient access to care.

That being said, the DMCB has two concerns:

1. If the DMCB is reading this right, it appears all persons of any age with diabetes were included in the study, including Type 1 diabetics.  If that's correct, that could have also blunted the impact of any disease management program, since children are over-represented in Medicaid and the impact of remote telephonic coaching in Type 1 is widely viewed (even among the disease management vendors) to be ineffective.  Insulin-requiring kids need lots of face-to-face hands-on care.

2. The DMCB is unfamiliar with the three study states' disease management programs, but if they were set up the "old fashioned way" to contact all persons with diabetes without the modern regard to future risk and "impactibility," then it's little wonder that the programs failed.  State-of-the-art population health management tailors its programs by focusing on subsets of persons with chronic conditions that are most likely to benefit.  Any impact on emergency room use or inpatient charges for these patients would be lost in the data "noise" of everyone else's utilization.

Should Medicaid programs that are facing huge jumps in enrollment abandon Medicaid as a result of this study?  Based on this study, the DMCB doesn't think so.  The findings are interesting, but more research is needed.
Posted by at No comments:
Labels: , , , , ,
Subscribe to: Posts (Atom)