Friday, November 21, 2014

Fwd: qotd: Medicaid improving access for the homeless, but…

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From: Don McCanne <>
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Subject: qotd: Medicaid improving access for the homeless, but…
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Kaiser Family Foundation
November 13, 2014
Early Impacts of the Medicaid Expansion for the Homeless Population
By Barbara DiPietro, Samantha Artiga and Alexandra Gates

The Affordable Care Act (ACA) Medicaid expansion offers a significant
opportunity to increase coverage and improve access to care for
individuals experiencing homelessness, who historically have had high
uninsured rates and often have multiple, complex physical and mental
health needs.

* The Medicaid expansion has led to significant increases in coverage
that are contributing to improved access to care and broader benefits
for homeless individuals. Providers reported that these coverage gains
have enabled patients to access many services that they could not obtain
while uninsured, including some life-saving or life-changing surgeries
or treatments. Participants also identified other broader benefits for
homeless individuals stemming from Medicaid coverage gains. For example,
providers noted improvements in individuals' ability to work and
maintain stable housing due to better management of health conditions.
In addition, participants said individuals have reduced financial stress
and improved access to other services and programs, including disability

* Providers reported having access to a broader array of treatment
options as a result of Medicaid coverage gains among their patients.
With these increased options, providers said they are better able to
provide care based on the best courses of treatment rather than based on
the availability of charity or discounted resources.

* Gains in Medicaid revenue are facilitating strategic and operational
improvements focused on quality, care coordination, and information
technology. In addition, administrators indicated that Medicaid revenue
gains supported staff increases and led to changing staff roles to meet
increased administrative and billing needs. However, participants
emphasized that, even with Medicaid revenue gains, other funding sources
remain vital for supporting the full range of services needed by the
homeless population.

* Participants from the non-expansion site (Florida - did not expand
Medicaid) indicated that their patients remain uninsured and are
continuing to face significant gaps in care that contribute to poor
health outcomes. Participants also said they are facing an increasingly
challenging financial situation because they are missing out on Medicaid
expansion revenue gains and other funding sources are declining.

* As homeless patients gain Medicaid coverage and are enrolled in
managed care, some challenges are emerging. Participants commented that
some patients are being auto-assigned to providers with whom they do not
have an existing relationship and/or they may have difficulty accessing
due to lack of transportation. Additionally, working within provider
networks can be difficult given the complex needs of individuals, lack
of transportation, and the limited experience among other providers in
serving this population. Lastly, participants emphasized that prior
authorization requirements and limited and/or changing drug formularies
are leading to delays in care for individuals and creating substantial
administrative burdens for providers.


Comment by Don McCanne

The experience of the homeless population under the Affordable Care Act
(ACA) demonstrates both the benefits of reform under ACA and the flaws
of ACA that call for replacement with a single payer system. ACA was
better than nothing, but we can have so much more through enactment of a
single payer system.

The primary ACA benefit for the homeless is that most of them in
expansion states qualify for Medicaid and thus have improved access to
health care without financial barriers. Some of the homeless who access
health care have been noted to have an increased ability to work and to
maintain stable housing. Financial stress is reduced and some have
gained access to appropriate disability benefits. These benefits to the
homeless are more reasons why calls for simple repeal of ACA are bad
policy, devoid of compassion.

Yet the last paragraph from the excerpts above explains why Medicaid
managed care is often a poor choice for the homeless (and many other
lower-income individuals as well). Homeless patients often are unable to
see the health care professionals who would be most accessible and
appropriate for them. Transportation concerns are more likely. Essential
specialized services may not be available. Managed care intrusions such
as prior authorization requirements, limitations and changes in
formularies, or other perverse managed care innovations may impair
access to important health care services or products. Further, those
states that refuse to expand Medicaid are leaving most of the homeless
without any coverage and therefore reliant on often inadequately funded
safety-net institutions.

There are those who believe that we should merely proceed with
implementation of ACA and try to obtain legislative and administrative
patches along the way. Compared to the deficiencies in our dysfunctional
system, patches have only minimal beneficial impact while increasing the
administrative complexity that already overburdens our system. Patches
fall way too short of what we need.

We should not repeal ACA since it does provide some temporary benefit
until we can implement a single payer system. But we should not let ACA
implementation divert us from instituting what we really need - a single
payer national health program. Not only would that benefit the homeless,
it would benefit all of the rest of us as well.

Thursday, November 20, 2014

Fwd: qotd: International comparison of patients over 65 - impact of Medicare

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Subject: qotd: International comparison of patients over 65 - impact of
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Health Affairs
November 2014 (online)
International Survey Of Older Adults Finds Shortcomings In Access,
Coordination, And Patient-Centered Care
By Robin Osborn, Donald Moulds, David Squires, Michelle M. Doty and
Chloe Anderson


Industrialized nations face the common challenge of caring for aging
populations, with rising rates of chronic disease and disability. Our
2014 computer-assisted telephone survey of the health and care
experiences among 15,617 adults age sixty-five or older in Australia,
Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden,
Switzerland, the United Kingdom, and the United States has found that US
older adults were sicker than their counterparts abroad. Out-of-pocket
expenses posed greater problems in the United States than elsewhere.
Accessing primary care and avoiding the emergency department tended to
be more difficult in the United States, Canada, and Sweden than in other
surveyed countries. One-fifth or more of older adults reported receiving
uncoordinated care in all countries except France. US respondents were
among the most likely to have discussed health-promoting behaviors with
a clinician, to have a chronic care plan tailored to their daily life,
and to have engaged in end-of-life care planning. Finally, in half of
the countries, one-fifth or more of chronically ill adults were
caregivers themselves.

Comparative US Performance And Challenges Going Forward

Despite having Medicare coverage, older US adults remained much more
likely to face financial barriers to care than their counterparts in
other developed countries. This may be surprising, as other studies have
found that Medicare offers more stable and protective insurance than
other forms of coverage in the United States, including
employer-sponsored private coverage. However, it is still clearly less
protective than the universal coverage offered in the health systems of
other countries surveyed. This finding likely reflects limitations in
Medicare coverage, including substantial deductibles and copayments,
especially for pharmaceuticals, which are often more expensive in the
United States than elsewhere. The absence of limitations on catastrophic
expenses and long-term care coverage likely play a role as well.

Financial barriers aside, elderly Americans also face comparatively poor
access to primary care and after-hours care, relatively high dependence
on the ED, and large gaps in care coordination. Yet the survey also
captures areas where the experience of US older adults is favorable.
Both comparatively and objectively, Americans reported good access to
specialists. The US health care system also performed relatively well
when it came to hospital discharge planning and on the more
patient-centered measures of health promotion, self-management support
for chronically ill patients, and support for end-of-life planning.

Finally, the US elderly population is sicker than the comparable
population in other surveyed nations, reporting a much higher incidence
of chronic disease. This higher disease burden will pose critical
challenges for US policy makers in years to come. The United States
already significantly outspends all of the other countries in the
survey—often by a two-to-one margin—despite having the youngest
population. Although the growth in health care costs has slowed in
recent years in all of these countries, these considerations suggest
that the United States will face growing cost pressures. It will be hard
to maintain the current low-growth trajectory unless the United States
successfully implements delivery and payment system reforms that reduce
the cost of care and finds a way to narrow the health gap between itself
and other countries.


Richard Gottfried, Chair, Committee on Health, New York State Assembly,
made the following observation: "The lesson: Living 65 years with
American insurance companies leaves you sicker. Then, transitioning to
American social insurance gives you quicker access to specialists."

(Personal communication, 11/19/14)


November 19, 2014
U.S. Seniors' Health Poorest, Global Survey Shows
By Steven Reinberg

Dr. Steffie Woolhandler, co-founder of Physicians for a National Health
Program, said American seniors are sicker because of the inadequate care
they received before they turned 65.

"The health care system for the under-65 population is full of gaps, and
lots of people fall through the cracks," she said.

Woolhandler, who is also a professor of health at CUNY School of Public
Health at Hunter College in New York City, added that Medicare is also
leaving many Americans underinsured and that the Affordable Care Act
will not make a major difference.

"We need to be providing much more comprehensive coverage to everyone,
including lower co-pays and deductibles," she suggested.


Comment by Don McCanne

This international comparison of health care in older adults in eleven
nations is the latest in the series sponsored by the Commonwealth Fund.
For the United States, it is unique in that it compares only patients
over 65 in our public Medicare program with older patients in other
nations that already have universal health care systems.

Perhaps the most remarkable finding for the United States is that
patients enter the Medicare program sicker than older patients in other
nations, but, once there, they have better access to health care than
those younger than 65. But even our Medicare program leaves our elderly
exposed to greater financial barriers to care than do the systems of
other nations.

This study once again shows what the United States needs is obvious. We
need to improve Medicare so that it provides better coverage, and then
we need to expand it to cover everyone.

Wednesday, November 19, 2014

Fwd: qotd: Prescription drug plans are adding more tiers and switching from co-pays to coinsurance

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Subject: qotd: Prescription drug plans are adding more tiers and
switching from co-pays to coinsurance
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November 13, 2014
Avalere Analysis: Medicare Beneficiaries Will Pay Higher Out-Of-Pocket
Costs As PDPs Increase Use Of Coinsurance In 2015
By Caroline F. Pearson, Vice President

First Time in History of Part D, All PDPs Will Incorporate a Specialty Tier

A new analysis from Avalere Health finds that Medicare Part D
prescription drug plans (PDPs) are poised to increase significantly the
use of coinsurance in 2015. Avalere found that two-thirds of standalone
Part D PDPs will apply coinsurance—i.e., consumers paying a percentage
of the total cost of the drugs—to at least their top two formulary
tiers, an increase of 83 percent from 2014.

"Adding coinsurance to a second plan tier means that more beneficiaries
will be looking at the full cost of branded drugs at the pharmacy
counter," said Dan Mendelson, CEO at Avalere Health. "This strategy has
proven central to plan operations as they try to keep premiums low to
maintain stability in Part D."

For First Time in History of Part D, All PDPs Will Incorporate a
Specialty Tier in 2015

Since the introduction of Part D in 2006, the use of specialty tiers has
been more common in Medicare Part D than in other markets, such as
employer-sponsored insurance. From 2012 to 2015, the number of Part D
PDPs using specialty tiers has increased, jumping nearly 15 percent in
four years. As a result, all PDPs will use a specialty tier in 2015, the
first time this has occurred in the history of Part D.

"The clear trend toward specialty tiers in exchanges and Part D is
likely to have an impact on employer-sponsored benefit designs over
time," said Caroline Pearson, Vice President at Avalere Health. "Benefit
managers and C-Suite executives are definitely taking notice of how
active management of the pharmacy benefit may be able to reduce premiums."

Two-Thirds of PDPs Will Use at Least Two Coinsurance Tiers

Perhaps more significant for beneficiaries and manufacturers is the
major shift toward the use of at least two coinsurance tiers in 2015.
Avalere's analysis found that 66 percent of PDPs in 2015, representing
60 percent of covered Medicare Part D beneficiaries, will apply
coinsurance to their top two tiers. In 2014, only 32 percent of PDPs
(representing 35 percent Part D beneficiaries) did the same. In total,
enrollment in plans with at least two coinsurance tiers increased from
6.4 million to 11.1 million from 2014-2015.

In most cases, these plans include one specialty tier and apply
coinsurance to the non-preferred brand tier. Unlike the specialty tier,
there are no restrictions on what drugs can be placed on non-specialty
coinsurance tiers, nor are there cost-sharing limitations. As a result,
many of these tiers have cost-sharing rates ranging from 35 to 50 percent.

The shift toward more than one coinsurance tier has been accompanied by
a shift toward formularies with five tiers. In 2015, 89 percent of plans
will have five or more tiers, a 53 percent increase since 2012. Indeed,
the dominance of five-tier plans can be accounted for in part by a surge
in the number of such plans with two coinsurance tiers in 2015—while
only three plans used this formulary structure in 2014, 335 plans will
do so in 2015. Among these plans, coinsurance on tier four (typically
used for non-preferred brand drugs) averages 44 percent.

"The inclusion of more coinsurance tiers on PDP formularies is designed
to increase plans' ability to obtain lower spending for high-cost – but
non-specialty – drugs," said Christine Harhaj, Senior Manager, Avalere
Health. "Unlike most specialty drugs, however, these treatments are
often prescribed to a broad patient population and applying coinsurance
rates may have the effect of significantly increasing cost sharing for a
large number of Part D beneficiaries."


Comment by Don McCanne

There has been an explosion in the introduction of very high cost drugs.
At the same time the generic drug market is being manipulated to enable
exponential increases in the prices of generic drugs. So what
innovations are the insurers introducing in response?

They are expanding the number of drug pricing tiers, and they are
switching from modest co-payments (fixed dollar amount) to much higher
coinsurance payments (a percentage of the actual costs), both of which
shift much more of the costs to patients. Many patients will go without
medications that they should have simply because the out-of-pocket costs
will be truly unaffordable.

The insurance industry prides itself on offering innovative products to
the public. But insurance innovations are designed to benefit the the
insurers. In a public insurance program, problems such as the excessive
prices of drugs are addressed through innovations that are designed to
benefit… wait for this… the patient!

A well designed single payer system would not use unbearable cost
sharing to try to address the high prices of drugs. Rather it would use
its power as a monopsony (single purchaser in a market) to demand fair
pricing of drug products based on legitimate costs and fair margins.
Those prices would be paid by our shared single risk pool, funded
through equitable taxes.

Really. If you didn't read the excerpts above, read them now to see what
a disaster these changes will be. And these are only changes introduced
in one year for one program - Part D Medicare - though the intent is to
extend these changes to employer-sponsored plans as well.

Just consider the changes that the private insurance industry makes in
every program every year - some subtle, some not so - and add those up
and you'll understand why we have an exorbitantly priced but mediocre
health care financing system. It's time to turn it over to our own
public administrators.