AHIP Steps Up With Their Version of Health Reform

While HHS Secretary Sebelius reassures the House Republicans that the Fed's health insurance exchanges are on track, that the implementation of the Affordable Care Act will not be a "train wreck" and flies around the country touting Obamacare, Disease Management Care Blog readers may want to check out this 3 page article by the notorious anti-Sebelius a.k.a. AHIP's CEO Karen Ignagni.  In it, she mounts a vigorous defense of her trade association's commercial insurer members.

She points out:

1) Commercial insurers' versions of accountable care organizations include a variety of prospective payment approaches that are tailored to the provider's willingness to take on insurance risk.  What's more, commercial insurers can "calibrate" the benefit so that consumers', physicians' and hospitals' economic incentives are all aligned.

2) Health plans are quite able to share data and analytics support that translates into early identification of trends, accurate payment designs and the targeting of programs at patients who are at greatest risk.

3) AHIP's members are routinely providing health risk assessment tools, predictive modeling, medication compliance programs and care management services.

4) AHIP is well aware of the difference between true cost savings versus mere cost shifting.  As a result, they are asking for greater transparency on commercial and government fee schedules so that the potential impact of cost shifting can be better understood.

5) While Washington DC deserves a lot of credit for promoting a quality agenda, it could do a better job of working with all insurers to come up with a set of universally used quality measures.

6) While commercial plans are required to use uniform billing systems, providers are under no obligation to submit their claims electronically.  While this certainly helps physicians over the short term, the long term inefficiencies are not cheap.

7) Commercial insurers would rather cover treatments that have been shown to work. The "Patient-Centered Outcomes Research Institute" is not mentioned by name, but you get the idea.

8) AHIP supports letting non-physicians practice "to the top of their license."

9) State-based "laboratories of democracy" are a useful way to try out a variety of health reforms before they are adopted by Washington.

The DMCB's take?

AHIP and Karen Ignagni have been mostly out of the public eye.  Could this be a sign that they're less wary of the Administration's anti-insurer bluster?

While Medicare's Innovation Center continues to get high marks, the commercial insurers appear to be advantaged by having more leeway to test new payment and care management strategies.

AHIP's members are aware that many providers could fold if they mismanage the risk that underlies prospective payment systems.  Unike Washington's one-size fits all approach, they seem prepared to adapt their contracting accordingly.

Care and disease management programs?  The commercial insurers have rolled this into standard operating procedure.

An Update On Population Health Management: It's Working!

CMS, MA Plans & Disease Management?

It's a good day when Health Affairs has nice things to say about population health management (PHM).  After all, Health Affairs is one of the bedside reading options for inside-the-beltway health care elites. So, when hostility to Ver. 1.0 disease management turns into a reasoned summary of Ver. 2 PHM, that's not only evidence of PHM's success but waning anti-vendor ideology. While the ultimate success of PHM is a function of market demand, this kind of endorsement can't hurt.

Using the Care Continuum Alliance's definition of PHM, researchers from America's Health Insurance Plans (AHIP) and Brandeis University conducted a written and then telephonic survey of 42 out of 72 larger Medicare Advantage (MA) Plans. While the results were interesting, what caught the Disease Management Care Blog's eye was that.....

Disease and case management are "routinely used." These programs are made up of nurse hotlines, telephone visits, increasing access to social services, meeting patients' psychosocial and providing care coordination. An accompanying infographic says "100%" offer "teaching chronic disease self-management."

Health risk assessments are also used "universally" and target self-identified individuals with outreach designed to educate and/or enroll in programs that reduce risk factors.

Care managers for the frail elderly are available in "100%" of plans. A second infographic points out that home safety, in-home visits and community services referrals are among the top used interventions. And, as testimony to a lingering sense of skepticism over remote home monitoring, the infographic says that was only used in 56% of plans.

Unlike Medicare fee-for-service (FFS), hospital readmissions have been a top concern of the MA Plans for years. They know there is no single "silver bullet" and have long relied on a combination of nursing, social services, home-health visits, medication reconciliations, follow-up care coordination programs and home visits. Survey respondents were convinced their programs were "effective."

In other examples of MA Plans being light-years ahead of Medicare FFS, if providers need data, MA Plans will make it available. If payment reform is necessary, MA Plans will make deals involving global risk arrangements, bundled payments and shared savings.

Evidence? Regretfully, say the authors, there is a lack of "systematic evidence" supporting PHM's effectiveness.  They also believe that there is conflicting evidence on whether MA Plans achieve better outcomes versus Medicare FFS.

The Disease Management Care Blog's take:

While skeptics continue to believe that Medicare Health Support "proved" that "disease management" doesn't work, the MA Plans correctly surmised that MHS only proved that early versions of disease management in Medicare FFS settings doesn't work.  The MA Plans have figured out how to improve on disease management.

While published data may be lacking, the people who run MA Plans are not dunces.  They have internal data showing that it works, or they wouldn't be using it.

While the Medicare Advantage program is controversial, the Health Affairs post suggests the MA Plans are useful laboratories for seeing what can be of benefit in the care of Medicare-eligible seniors.  If ACOs flop, perhaps CMS will go back to the future with their MA Program for ideas on what can work.

The Genetic Information Nondiscrimination Act (GINA), Health Risk Assessments (HRAs) and Lawyers Run Amok

The Disease Management Care Blog received a DMAA email containing this press release today. It calls for a moratorium in "GINA regulation implementation."

What's this about you ask? The DMCB at your service.

GINA is part of the logarithmically expanding blob of Washington D.C. acronyms. This particular one refers to the 'Genetic Information Nondiscrimation Act' that was signed into law by President Bush on May 21, 2008. Its intent was to prevent discrimination based on genetic information by health insurers and employers.

In reading about the act here, it appears that the way discrimination is prevented is by prohibiting employers and health insurers from collecting any genetic information in the first place. In addition to not collecting it, insurers are also prohibited from using it for decisions about coverage or rates (by insurers) or for hiring, firing, promotions or other decisions about the terms of employment (employers).

So far so good.

So the intrepid DMCB went to the text of the law itself and found a lot of language stating that collecting and use of 'genetic information' was prohibited in health insurance 'underwriting.' The statute has very clear definitions of underwriting ('health insurance rules used to determine eligibility, computation of premiums, exclusions of pre-existing conditions and other activities related to contracting health benefits') and genetic information ('results of genetic tests of the individual or the family members and the manifestation of a disease or disorder in family members of an individual').

The DMCB is struck by the inclusion of 'family history.' Read on and you'll see why.

On Oct 7, 2009, the Departments of Labor, Treasury, HHS and the Equality Employment Opportunity Commission released proposed regulations a.k.a interim final rules that are intended to guide their interpretation and enforcement of GINA. The rules become effective on December 8, 2009.

The lawyers that crafted these regulations must have also been struck by the term 'family history,' because they've addressed it in the context of health risk assessments (HRAs).

HRAs are widely used in the population-based health care. It typically consists of questionnaire that asks a series of health related questions. The individual answers can then be summed up to determine an overall risk score in one or more health domains. This is an example of an HRA used to assess the risk from being overweight, while this HRA determines the risk of future heart attack. Note that both of these examples include family history as one factor in the overall assessment of risk.

What do the interim final rules say? They correctly point out that HRAs that include family history questions are typically distributed at the time of new or re-enrollment and are often accompanied by incentives to complete the survey. When present, these incentives consist of rewards such a premium reductions, lower deductibles and cash bonuses. Since this is money that is tied to the premium which is defined to be part of underwriting, the practice will become illegal on December 7.

What's more, if the HRA is requested prior to enrollment, even if there is no payment to the enrollee, the act of collecting the 'genetic information is also a violation of the law.

If your disease management organization, population-based care company, employees benefit plan or health insurer uses HRAs at the time of open enrollment, you have two choices:

Change how the HRA is done: No financial incentives, period. What's more, the HRA can't be distributed or collected until after enrollment,

or

Strip all the family history questions out of the HRA.

The DMCB agrees with the DMAA that the interim rules need to be put on hold until this twisted pretzel logic of lawyers run amok is straightened out.

First of all, while inquiries about family history can be intrusive to individuals completing HRAs, the cash value of the incentives are undoubtedly very welcome and are a fair value transaction.

The DMCB also did a word search of the original statute and did not find the term 'health risk assessment.' It doubts our legislators intended to sweep HRAs into the scope of this legislation.

It is also illogical to group the practice of increased payment to all enrollees with and without significant family histories with the other repugnant practices of charging more or denying benefits on the basis of genetic history. The resemblance is superficial to anyone with common sense.

In addition, in real practice, it is highly unlikely that the underwriters in any health plan would harvest the data from HRAs and mathematically price it into their premium decision-making. It is theoretically possible, but that's simply not how the business is operates.

Last but not least, the risk of harm from showing some flexibility around this topic is far less than the risk of harm from hobbling how HRAs are distributed, completed and used. Thanks to HRAs, companies are not only extending hard cash but using the information to provide a higher level of service to individuals who would benefit from it.

If the DMCB is reading things right, comments on this silliness can apparently still be submitted (E-OHPSCA.EBSA@dol.gov) through January 5, 2010. The DMCB copied the above text and simply emailed it in over its signature.