Monday, March 31, 2014

Fwd: qotd: The High Burden of Health Care Costs on Insured Adults

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-------- Original Message --------
Subject: qotd: The High Burden of Health Care Costs on Insured Adults
Date: Mon, 31 Mar 2014 12:05:31 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



BCBS of Mass Foundation, RWJ Foundation, Urban Institute
Beyond Coverage: The High Burden of Health Care Costs on Insured Adults
in Massachusetts
March 2014
By Sharon K. Long

These findings highlight the vulnerability that Massachusetts families
experience when faced with high health care costs. Overall, 42.5 percent
of all nonelderly adults in the state reported that health care costs
had resulted in financial problems or health care access problems for
their families in the past year, with the burden greater for low-income
adults (46.5 percent for those with income at or below 138 percent FPL)
and middle-income adults (53.9 percent for those with income between 139
and 399 percent FPL). Nearly three-quarters (70.6 percent) of those who
were uninsured for all or part of the year reported problems with health
care costs. However, neither higher income nor health insurance coverage
protected Bay State families: 31.7 percent of higher-income adults and
38.7 percent of adults with insurance coverage for the full year also
reported that health care costs had resulted in problems for their families.

Health care costs are creating difficult choices for families in
Massachusetts. Insured adults frequently reported going without needed
care because of costs, cutting back on non-health-related spending to
pay for health care, and reducing their family's financial security to
pay for health care, both by reducing savings and by taking on debt,
including credit card debt. As a result, medical debt had a significant
impact on many families, particularly middle-income families, with
contacts from collection agencies quite common.

http://bluecrossmafoundation.org/sites/default/files/download/publication/MHRS%20Beyond_Coverage.pdf

****

Health Affairs Blog
March 26, 2014
Health Insurance Coverage Is Just The First Step: Findings From
Massachusetts
By Sharon Long, Kate Willrich Nordahl, Kaitlyn Kenney Walsh, Kathy
Hempstead, and Ariel Fogel

The challenges faced by low-income and middle-income Massachusetts
families are particularly worrisome given that the consumer protections
for out-of-pocket health care costs are generally better in
Massachusetts than those required under the ACA. For individuals with
family income between 100 and 200 percent of poverty who are enrolled in
the state's subsidized health insurance program, out-of-pocket spending
for covered prescriptions and medical services is limited to $1,000 per
benefit year. The ACA allows individuals in this income cohort to have
out-of-pocket costs that can sum to more than double this amount ($2,250).

http://healthaffairs.org/blog/2014/03/26/health-insurance-coverage-is-just-the-first-step-findings-from-massachusetts/

****


Comment by Don McCanne

The provisions of the Affordable Care Act (ACA) have provided the nation
with health care coverage similar to that which has existed in
Massachusetts. However, "the consumer protections for out-of-pocket
health care costs are generally better in Massachusetts than those
required under the ACA." Though Massachusetts has better coverage,
"Overall, 42.5 percent of all nonelderly adults in the state reported
that health care costs had resulted in financial problems or health care
access problems for their families in the past year."

Over half of middle-income adults in Massachusetts also "reported that
health care costs had resulted in financial problems or health care
access problems for their families."

Furthermore, "neither higher income nor health insurance coverage
protected Bay State families: 31.7 percent of higher-income adults and
38.7 percent of adults with insurance coverage for the full year also
reported that health care costs had resulted in problems for their
families."

This is the shocking truth about our new national standard of
underinsurance: In spite of having greater financial protection than
that offered through the Affordable Care Act, over one-half of
middle-income adults and nearly one-third of higher-income adults in
Massachusetts still had problems with health care costs. And many of
those who didn't have problems likely avoided them by being fortunate
enough to remain healthy. That is not the way an egalitarian health care
financing system should work.

This ACA turkey won't fly. All of us, including many of those with
higher incomes, would benefit from single payer.

Friday, March 28, 2014

Fwd: qotd: Canada is paying more and getting less from private insurers

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-------- Original Message --------
Subject: qotd: Canada is paying more and getting less from private insurers
Date: Fri, 28 Mar 2014 12:31:55 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Medical Xpress
March 24, 2014
Canadians spend more on private health insurance for smaller payouts

Spending by Canadians on private health insurance has more than doubled
over the past 20 years, but insurers paid out a rapidly decreasing
proportion as benefits, according to a study published today in the CMAJ
(Canadian Medical Association Journal).

The study, by University of British Columbia and University of Toronto
researchers, shows that overall Canadians paid $6.8 billion more in
premiums than they received in benefits in 2011.

Approximately 60 per cent of Canadians have private health insurance.
Typically obtained as a benefit of employment or purchased by
individuals, private health insurance usually covers prescription drugs,
dental services and eye care costs not paid by public health care.

Over the past two decades, the gap between what insurers take in and
what they pay out has increased threefold. While private insurers paid
out 92 per cent of group plan insurance premiums as benefits in 1991,
they paid only 74 per cent in 2011. Canadians who purchased individual
plans fared even worse, with just 38 per cent of their premiums returned
as benefits in 2011.

"Small businesses and individual entrepreneurs are the hardest hit –
they end up paying far more for private health coverage," says study
lead author Michael Law, an assistant professor in UBC's Centre for
Health Services and Policy Research, "It's essentially an extra health
tax on one of our main economic drivers.

"Our findings suggest that private insurers are likely making greater
profits, paying higher wages to their executives and employees, or
spending more on marketing," Law adds.

http://medicalxpress.com/news/2014-03-inefficiency-private-health-canada.html

CMAJ article (first page, paywall for rest)
http://www.cmaj.ca/content/early/2014/03/24/cmaj.130913.extract


Comment by Don McCanne

Although Canada's single payer system provides excellent coverage for
most health care, a market for private health insurance sprung up to
cover prescription drugs, dental services and eye care that were not
covered by the original program. The for-profit insurers did what they
are expected to do. They began by retaining 8 percent of premiums for
administrative costs and profits. But after two decades, they now retain
as much as 62 percent of premiums for profits, high executive
compensation, marketing and other administrative costs.

Although some are calling for more regulation of Canada's private
insurers, they should have learned from the experience in the United
States. No amount of regulation will eliminate their inefficiencies and
waste. Coverage for these services should be rolled over into the public
single payer system.

Opponents protest that Canada cannot afford to offer these benefits in
their public program. Nonsense. Most Canadians are already receiving
drugs, dental care and eye care, and it is being paid for out-of-pocket
or through private insurance. The money is already being spent; it just
needs to be spent better. Placing these benefits into the public program
would do the following things: 1) administered pricing would ensure
value, 2) financial barriers to care would be reduced, 3) financing
would be more equitable, and 3) the excesses and waste of the private
insurers would be eliminated.

When we enact our single payer system here in the United States, we'll
need to be sure that we don't make the same mistakes as Canada, though
they are far fewer than our blunders.

Wednesday, March 26, 2014

Fwd: qotd: CORRECTION: Matt Anderson questions his "medical home"

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-------- Original Message --------
Subject: qotd: CORRECTION: Matt Anderson questions his "medical home"
Date: Wed, 26 Mar 2014 10:35:16 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



(Link to Matt Anderson's article inadvertently omitted - now inserted
following the excerpts)


Health Affairs Blog
March 17, 2014
Nine Questions About My New Medical Home
By Matthew Anderson

Sometime in the past five years — it's hard for me to say exactly when —
I suddenly found myself living in a new home. I must admit I am still a
bit disoriented by how this happened. But it did. People keep telling me
that everything will be ok but I am not entirely sure.

1. Is this a home or is it a hostel?

2. Will my old friends still be welcome in my new home?

3. Does Mommy love me or is she just paid to say so?

4. Why are we playing computer games during family time?

5. Are there any family secrets left?

6. Everyone tells me how important I am, so why is my allowance being cut?

7. Do I have to go to Church now?

8. Can we get some family therapy?

9. Can't we afford a better home?

There was a time when family medicine saw itself as a counter-culture in
medicine with a mission to incorporate a different set of values. Our
job should be to improve the wellbeing and health of our patients and
their communities, not the bottom line of the corporations who thrive
off our labor.

Such a dream will not happen until health care is seen as a public good
instead of a private commodity. A national health system, it seems, is
the only economically rational and humane way forward.

http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/

****


Comment by Don McCanne

What is a patient-centered medical home? To some it means the place you
go to get health care - full primary care and a convenient and efficient
entry path into more specialized services. To others it means a way of
organizing the business of health care to make it more accountable for
reducing costs, guided by the dictates of private insurers and
government bureaucrats implementing the Affordable Care Act.

Matthew Anderson's nine questions about the nature of the medical home
should serve as a teaser to read the full article on the Health Affairs
Blog. It is not simply about the medical home concept, but it questions
the whole direction in which our health care system is headed. Not only
should you read it, but you should download it and share it with others.

Dr. Anderson has the right values. He is a driving force behind The
Social Medicine Portal (An Alternative to Corporate Health) and an
editor of the journal, "Social Medicine."

The Social Medicine Portal:
http://www.socialmedicine.org/welcome-to-the-social-medicine-portal/

Social Medicine:
http://www.socialmedicine.info/index.php/socialmedicine/index

Repeating his astute words, "Our job should be to improve the wellbeing
and health of our patients and their communities, not the bottom line of
the corporations who thrive off our labor. Such a dream will not happen
until health care is seen as a public good instead of a private
commodity. A national health system, it seems, is the only economically
rational and humane way forward."

Fwd: qotd: Matt Anderson questions his "medical home"

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-------- Original Message --------
Subject: qotd: Matt Anderson questions his "medical home"
Date: Wed, 26 Mar 2014 10:01:56 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs Blog
March 17, 2014
Nine Questions About My New Medical Home
By Matthew Anderson

Sometime in the past five years — it's hard for me to say exactly when —
I suddenly found myself living in a new home. I must admit I am still a
bit disoriented by how this happened. But it did. People keep telling me
that everything will be ok but I am not entirely sure.

1. Is this a home or is it a hostel?

2. Will my old friends still be welcome in my new home?

3. Does Mommy love me or is she just paid to say so?

4. Why are we playing computer games during family time?

5. Are there any family secrets left?

6. Everyone tells me how important I am, so why is my allowance being cut?

7. Do I have to go to Church now?

8. Can we get some family therapy?

9. Can't we afford a better home?

There was a time when family medicine saw itself as a counter-culture in
medicine with a mission to incorporate a different set of values. Our
job should be to improve the wellbeing and health of our patients and
their communities, not the bottom line of the corporations who thrive
off our labor.

Such a dream will not happen until health care is seen as a public good
instead of a private commodity. A national health system, it seems, is
the only economically rational and humane way forward.

****


Comment by Don McCanne

What is a patient-centered medical home? To some it means the place you
go to get health care - full primary care and a convenient and efficient
entry path into more specialized services. To others it means a way of
organizing the business of health care to make it more accountable for
reducing costs, guided by the dictates of private insurers and
government bureaucrats implementing the Affordable Care Act.

Matthew Anderson's nine questions about the nature of the medical home
should serve as a teaser to read the full article on the Health Affairs
Blog. It is not simply about the medical home concept, but it questions
the whole direction in which our health care system is headed. Not only
should you read it, but you should download it and share it with others.

Dr. Anderson has the right values. He is a driving force behind The
Social Medicine Portal (An Alternative to Corporate Health) and an
editor of the journal, "Social Medicine."

The Social Medicine Portal:
http://www.socialmedicine.org/welcome-to-the-social-medicine-portal/

Social Medicine:
http://www.socialmedicine.info/index.php/socialmedicine/index

Repeating his astute words, "Our job should be to improve the wellbeing
and health of our patients and their communities, not the bottom line of
the corporations who thrive off our labor. Such a dream will not happen
until health care is seen as a public good instead of a private
commodity. A national health system, it seems, is the only economically
rational and humane way forward."

Tuesday, March 25, 2014

Fwd: qotd: Are we forgetting about the underinsured?

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-------- Original Message --------
Subject: qotd: Are we forgetting about the underinsured?
Date: Tue, 25 Mar 2014 11:06:52 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



The Commonwealth Fund
March 2014
America's Underinsured
By Cathy Schoen, Susan L. Hayes, Sara R. Collins, Jacob A. Lippa, and
David C. Radley

The twin goals of health insurance are to enable affordable access to
health care and to alleviate financial burdens when injured or sick. It
is well known that the uninsured are at high risk of forgoing needed
care and of struggling to pay medical bills when they cannot postpone
care. Studies further find that insured people who are poorly protected
based on their households' out-of-pocket costs for medical care are also
at risk of not being able to afford to be sick.

Using newly available data from census surveys, this report provides
national and state-level estimates of the number of people and share of
the population that were insured but living in households that spent a
high share of annual income on medical care in 2011–12. In the analysis,
we refer to these people as "underinsured." However, this group is only
one subset of the underinsured. Our estimates do not include insured
people who needed care but went without it because of the out-of-pocket
costs they would incur, or the insured who stayed healthy during the
year but whose health insurance would have exposed them to high medical
costs had they needed and sought care.

The analysis finds that in 2012, there were 31.7 million insured people
under age 65 who were underinsured. Together with the 47.3 million who
were uninsured, this means at least 79 million people were at risk for
not being able to afford needed care before the major reforms of the
Affordable Care Act took hold.

In all states, people with low incomes are at greatest risk for being
underinsured or uninsured. Nationally, in 2012, nearly two-thirds (63%)
of those with incomes below the federal poverty level were either
underinsured or uninsured. Among those with incomes between 100 percent
and 199 percent of poverty, nearly half (47%) were underinsured or
uninsured.

A decade or more of people losing health coverage and a steady erosion
in the financial protection of insurance has also put middle-income
families at risk. In 2012, one of five people (20%) under age 65 with
middle incomes (between 200% and 399% of poverty)—an estimated 15.6
million people—were either underinsured or had no health insurance.

Low- and Middle-Income Households Most at Risk

The exposure to high out-of-pocket medical care costs even when people
have insurance reflects insurance trends — including higher deductibles
and cost-sharing, as well as gaps in benefits or limits on coverage — in
both the employer and individual insurance markets. This puts insured
families at risk in terms of access to health care and financial well-
being. Studies indicate that low- and middle-income insured individuals
and families who face high out- of-pocket costs for medical care
relative to their incomes are nearly as likely as the uninsured
population to go without care because of costs, forgo care when sick,
struggle to pay medical bills, or incur medical debt. Both population
groups — underinsured and uninsured — are at far higher risk of access
or medical bill concerns than those with more protective coverage.

Premiums for Employer-Sponsored Insurance Have Risen More Rapidly Than
Incomes, Value of Benefits Declined

Over the past decade, the cost of health insurance has risen far faster
than incomes for middle- and low-income working-age families.

At the same time that premiums have risen, the value of benefits has
declined. Deductibles more than doubled for plans provided by larger and
small employers. This increase — plus other cost-sharing or limits on
benefits — has left insured patients paying a higher share of medical
bills. With little or no growth in incomes over a decade, insurance and
care have become less affordable.

Medicaid and Income-Related Premium Assistance

Using newly available information on out-of-pocket payments for
premiums, we estimate that 29 million insured people — 11 percent of the
total under-age-65 population and 13 percent of the insured population
under age 65 — paid premiums that exceeded the Affordable Care Act
premium contribution thresholds for those at their household income
level before reforms. In other words, they had high premium
out-of-pocket costs compared with incomes, with "high" defined as in
excess of Affordable Care Act contribution thresholds.

However, not everyone who pays high premiums relative to income will be
eligible for help. The 29 million insured people includes 13.7 million
with incomes below 138 percent of poverty who are paying premiums above
the Affordable Care Act thresholds for this group. Of these, 8.8 million
had private insurance they bought on their own or through employers.
Based on their income alone, they would likely be eligible for expanded
Medicaid if their state decides to participate in Medicaid expansions.

For those with incomes above Medicaid eligibility, the law restricts
eligibility for premium assistance in marketplaces to people buying
insurance on their own and to workers who have employer coverage where
the employee's premium costs for self-only coverage exceeds 9.5 percent
of income. Among the 29 million insured with high premium costs in 2012,
11.7 million had employer-sponsored coverage and incomes that would be
too high to qualify for expanded Medicaid.

Medicaid Expansion Makes a Critical Difference

Many of the states not participating in Medicaid expansion have among
the highest rates of uninsured or underinsured people as a share of
their total state populations. Without Medicaid expansion, this
vulnerable group will remain at high risk for access, health, and
financial problems.

Changing the Insurance Map of the Country

Substantial gains, however, will depend on the plans people choose and
state efforts to ensure high-value benefit designs and accessible
networks. One concern is to what extent people with low or modest
incomes will opt for "bronze" level plans. People choosing bronze-level
plans will pay 40 percent of medical care costs on average and thus
remain at financial risk. Additionally, in choosing a bronze plan,
people with low incomes forgo the cost-sharing subsidies that are tied
to silver plans that substantially reduce out-of-pocket spending for
medical care. As of February 2014, 62 percent of those enrolling in the
new marketplaces selected silver plans, 19 percent had selected gold or
platinum, and 19 percent had selected bronze.

In addition, it is important to note that the Affordable Care Act's
limits on out-of-pocket costs for covered benefits also apply only to
in-network providers. As discussed in a recent report profiling insured
people with medical debt, even with the new limits, the insured may
encounter high medical care costs if they receive care from
out-of-network clinicians.

From the Conclusion

However, the new marketplaces offer plans that include substantial
cost-sharing and annual caps on out-of-pocket patient costs that apply
to in-network providers only. With these benefit designs, there is the
risk that the nation could convert the uninsured into the underinsured
and fail to stop the erosion in insurance protections for people with
private insurance coverage.

Full report (40 pages - several Exhibits and Tables):
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2014/Mar/1736_Schoen_americas_underinsured.pdf


Comment by Don McCanne

This Commonwealth Fund report provides an estimate of the numbers of
underinsured - people who could experience financial hardships and
impaired access in the face of medical need. Although the authors
express optimism that the numbers of uninsured will decline as a result
of the provisions of the Affordable Care Act (ACA), there is a high
probability that there will be a substantial increase in the numbers of
people who will be underinsured.

The private insurance design features supported by ACA makes continued
underinsurance an inevitability. The insured are vulnerable because of
low actuarial value plans with high-deductibles and other cost sharing,
narrow and ultra-narrow networks that impair access to in-network
providers, inadequacies of the subsidies, and the perpetuation of an
expensive, administrative wasteful model of financing care - a model
that we all pay for, including the underinsured.

What is not expressed in the Commonwealth data is the number of people
who may not have attempted to access care because of concerns of high
out-of-pocket costs. Studies have shown that these people do forgo care
that they should have.

A sobering thought is the even larger numbers of individuals not
represented in this study. These are the people who remained healthy and
never had to test the adequacy of their insurance. Tens of millions of
people are vulnerable and would become financially insecure if they did
develop significant health problems. This includes many individuals with
employer-sponsored insurance. They are underinsured and don't know it.
Excluding these individuals from the underinsured count results in
estimates far below the actual numbers.

The design of ACA makes it clear that both the uninsured and
underinsured will remain a problem in the foreseeable future, but it
will be underinsurance that will likely provoke widespread discontent.
Its prevalence may well become the most compelling reason to abandon the
perversities brought to us by the private insurance industry. People
will be ready to replace our dysfunctional system with a single payer
national health program that would eliminate, for everyone, financial
barriers to health care.

Monday, March 24, 2014

Fwd: qotd: AHIP's Ignagni rejects mandate for comprehensive benefits

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-------- Original Message --------
Subject: qotd: AHIP's Ignagni rejects mandate for comprehensive benefits
Date: Mon, 24 Mar 2014 12:51:42 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



C-SPAN
March 21, 2014
Newsmakers
Karen Ignagni, President and CEO of America's Health Insurance Plans (AHIP)

Karen Ignagni: I would say that what we've learned - and I want to go
back to this whole transition point - the reason that the decision was
made to allow people to stay in their plans is because there was concern
being expressed about ten categories of coverage - no matter how
meritorious each and every one of those benefits may be - for an
individual purchasing, or a small business, sometimes from where they
started, which, in general, the old market had very high deductibles -
that's what people preferred to buy because they wanted to keep their
premiums low. Then if you take ten categories of coverage and you have a
giant step up, well that is a bridge too far for some individuals. And
that was being telegraphed pretty clearly in the fall, not from us but
from people who were buying the product and would have to spend more. So
I would create a lower tier so that people could gradually get into the
program, so they could be part of the risk pool so we don't hold the
healthier people outside, so the process could be working the way it was
designed, so we get the healthy and the sick. And I think doing things
gradually, just from human nature perspective, it just makes more sense.

Marry Agnes Carey: Wouldn't a lot of healthy people congregate in that
lower tier?

Karen Ignagni; Not necessarily. We're not seeing that right now in the
bronze, silver and gold. I think by that hypothesis you would have
expected an extraordinary amount of people to buy bronze and they have
chosen more silver, which is not as high deductible. So they wanted to
lower their deductibles. They're willing to pay a little bit more per
month. But the point is that people are choosing. What I would do is
give people more choices. I just… human nature suggests that people like
that. They're in control if they have more choices.

http://www.c-span.org/video/?318396-1/newsmakers-karen-ignagnino


Comment by Don McCanne

One of the more important goals of health care reform was to require
plans to provide comprehensive benefits. Although, as with other
compromises in the Affordable Care Act (ACA), the legislation fell
short, at least they did require that ten categories of benefits be
covered, even if insurers were allowed considerable flexibility within
each of the ten categories. Now AHIP - the insurers' lobby organization
- is attempting to dismantle the benefit requirement.

Suppose we said that males could decline obstetrical benefits if they
wanted to, or females could decline prostate cancer benefits, or
non-drug using monogamists could decline HIV/AIDS benefits, or young
invincibles could decline all benefits except physical trauma, or
whatever, what would happen to the risk pooling function of insurance?
Obviously that would violate one of the the most important functions of
prepaid health care - pooling all risks. Fragmenting risks into a
multitude of pools moves away from prepaid health care for everyone and
toward each person becoming responsible for paying for the care they
use. At the extreme is requiring everyone to pay full costs in cash. How
far along that polarity do we move - moving from bad to worse?

Creating another tier below the lowest current metal level - bronze -
meets the desires of insurers who want to expand their markets by
offering really cheap plans that exclude major benefits, but it does so
at a cost of breaking up the risk pools such that people with expected
higher costs are concentrated in comprehensive plans, driving premiums
up to ever less affordable levels.

"Erin," responding on the KHN Blog, suggested that we call this new
lower metal tier "pyrite" or fool's gold.

Look how the insurance industry has manipulated the goals of health care
reform:

* We wanted to include everyone, and 31 million people will be left out.

* We wanted to reduce financial barriers to care, and the insurers
reduced the actuarial value of their plans by increasing financial
barriers to care in the form of deductibles and other cost sharing.

* We wanted to slow total spending to sustainable levels. If that is
successful under ACA, it will be accomplished by preventing access to
essential health care through limited networks and excessive cost
sharing, not through true efficiencies such as are found in single payer
systems.

* We wanted to improve quality and instead the insurers sell us more
worthless administrative services to play ACO and P4P games.

* We wanted to reduce administrative waste, and instead we add greater
administrative complexity through the establishment of insurance
exchanges and accountable care organizations.

* We wanted everyone to have comprehensive benefits, and now the
insurers bring up the old saw about "giving people more choices" because
that puts people "in control" and people "like that." So let's strip out
their benefits so they can choose cheaper plans that relieve insurers of
the pesky need of covering expensive disorders.

Single payer would have achieved these goals, but the insurers keep
chiseling away at them to meet their own business needs while
sacrificing health care for the people. We can't seem to fix the
insurers, so let's get rid of them.


(Karen Ignagni said that people are willing to pay more for the silver
plans in order to lower their deductibles, but that is not the reason.
Since Congress knew that people would select plans with the lowest
premiums and thus have grossly inadequate coverage - bronze plans with
60% actuarial value - they prohibited those selecting bronze plans from
receiving cost-sharing subsidies for out-of-pocket expenses, forcing
them to buy up at least to the still inadequate silver plans with 70%
actuarial value. Karen Ignagni knows this, so she was being dishonest by
covering it up with the people-liking-choice spin, when all choices are
bad - except single payer of course.)

Friday, March 21, 2014

Fwd: qotd: Buying platinum and getting bronze

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-------- Original Message --------
Subject: qotd: Buying platinum and getting bronze
Date: Fri, 21 Mar 2014 12:08:43 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Bloomberg Businessweek
March 20, 2014
Obamacare Limits Choices Under Some Plans
By John Tozzi

Ben Rosenthal was treated for prostate cancer four years ago and had
gallbladder surgery the year before that. A former manager at a
market-research firm in Los Angeles, Rosenthal, 57, paid for his own
health insurance. Last fall, when his plan was discontinued because it
didn't meet standards set by the Affordable Care Act, Rosenthal bought
the best insurance coverage he could find, a top-tier "platinum" policy
from Blue Shield of California that costs $792 a month. He figured it
would provide access to top hospitals. Then in February he learned the
plan wouldn't cover the hospitals where he was used to being treated.

Rosenthal is one of millions of Americans who have purchased insurance
under the Affordable Care Act and are discovering that many of the new
plans offer a narrow network of doctors and facilities. "If I had
anything happen, I wouldn't want to go to a hospital that I'm not
familiar with and with doctors I don't know," he says.

Since the ACA created marketplaces for private health plans last fall,
insurers expecting to lure customers with low premiums have fashioned
smaller networks of medical providers. By cutting out expensive
hospitals and negotiating favorable rates with doctors in exchange for
sending more patients their way, insurers can keep premiums down. Blue
Shield's new network includes 43 hospitals in Los Angeles County, about
64 percent of what its standard coverage offers, spokeswoman Lindy
Wagner says in an e-mail.

In addition to having fewer options, buyers are making decisions about
which plans to buy based on incomplete or misleading information, says
Karen Pollitz, senior fellow at the Kaiser Family Foundation, a health
policy research group. "Consumers have a very limited ability to shop in
advance and evaluate provider networks," she says.

Plans on healthcare.gov <http://healthcare.gov> and state marketplaces
are required to include links to directories that show which providers
accept the insurance. But the information is often missing, wrong, or
difficult to navigate, says Oliver Kharraz, chief operating officer of
ZocDoc, an online appointment booking company. ZocDoc tried to verify
the accuracy of hundreds of directories by calling doctors listed as
in-network providers. About half the listings were wrong, Kharraz says.
The California exchange, one of 15 state marketplaces that operate
independently of healthcare.gov <http://healthcare.gov>, created a
central directory on its website but took it down on Feb. 6 because of
errors.

Pressures on insurers to keep premiums low—state regulators can reject
plans that are priced too high—may mean patients will have to learn to
live with restricted choices. "The industry's had to find ways to cut
costs," says Hasday of Frenkel Benefits. The result, he says, is "much
less transparent for the consumer."

Reader comment:

John Alexander
I had the exact same problem as Mr. Rosenthal only in Florida with Blue
Cross Blue Shield. Got screwed, as I also picked the Platinum plan and
found out my hospital and doctors were not covered. The best research I
did before hand indicated I would be covered and found after the fact I
was not. Got furious with BCBS and they agreed to correct a few cost
items with my doctors. They are playing dollar games with our health and
I am completely frustrated. I am not upset with Obama-Care, only with
the sligh and sneaky Insurance companies. Cannot drop my insurance
and/or change until November of this year. What a fiasco. A singly payer
system would correct all of this smoke and mirror games played by the
Insurance industry.

http://www.businessweek.com/articles/2014-03-20/obamacare-limits-choices-under-some-plans

****

The American Enterprise Institute (AEI)
January 24, 2014
In Obamacare, go for bronze health plans. For most people, buying up to
gold or platinum plans is a waste of money
By Scott Gottlieb

We analyzed dozens of Obamacare plans, and found one striking result.
The networks of providers, and in many cases the drug formularies, are
the same whether you're buying a particular insurer's bronze plan, or
purchasing the same insurance option in a gold or platinum offering. My
American Enterprise Institute colleague Kelly Funderburk and I posted
some of our data here.

The bottom line is this. When you're choosing a particular insurance
offering, you typically can't trade up to a better benefit by buying the
gold or platinum variety of that plan. It's usually the exact same
benefit regardless of the metal you choose.

So what varies between these different metal plans? Typically, just the
co-pay structure and deductibles. As you pay higher premiums for a gold
or platinum plan, your deductibles and co-pays will decline. The insurer
will typically cover 60 percent of expected medical expenses in a bronze
plan, 80 percent in a gold plan and 90 percent in a platinum plan. So,
by buying the costlier plans, all you're doing is fronting a higher
premium to buy down your anticipated out of pocket costs. You're not
getting a better network of doctors or a better formulary of drugs.

http://www.aei.org/article/health/in-obamacare-go-for-bronze-health-plans-for-most-people-buying-up-to-gold-or-platinum-plans-is-a-waste-of-money/

Data to support this claim:
http://www.scribd.com/doc/201871033/Comparison-of-Bronze-Versus-Platinum-Obamacare-Plans

****

McKinsey & Company
December 14, 2013
Hospital networks: Configurations on the exchanges and their impact on
premiums

Narrow and ultra-narrow hospital networks are more prevalent (70 percent
of all networks), increasing the variety of network configurations
available to consumers

Broader network offerings are fewer than in 2013, yet remain available
in almost every rating area we analyzed. The prevalence of narrower
networks varies across markets, with the average percent contraction of
incumbents' network breadth between 2013 individual market networks and
2014 individual exchange networks ranging from 11 to 60 percent.

Products with broad hospital networks reveal higher premiums, with a
median premium increase of 26 percent between broad and narrower
networks of the same carrier, product type (e.g., HMO, PPO), metal tier,
and rating area. Also, the majority (84 percent) of lowest-price silver
products utilizes narrow or ultra-narrow networks

Across silver tier networks in our 20 analyzed rating areas, 58 percent
of the lowest-price products utilize ultra-narrow networks and another
26 percent utilize narrow networks. Network breadth appears to be
positively correlated with premium levels in many cases, but the use of
narrower networks is common at all price points.

http://www.mckinsey.com/client_service/healthcare_systems_and_services/latest_thinking

****

Remapping Debate
October 30, 2013
Out-of-network coverage in New York? We left it up to the insurers
By Craig Gurian

New York's health insurance exchange (called "NY State of Health")
offers individuals and families numerous insurance plan options at
various "metal" levels. What it doesn't offer in most parts of the state
are plans that provide coverage for non-emergency out-of-network care.
In a sample Manhattan zip code, for example, there are 62 plans
available at all metal levels. Not one of those plans pays for
out-of-network care.

Why then did New York State not require out-of-network coverage? "We
left it up to the insurers," said (Department of Health's Randi)
Imbriaco, and the insurers, she continued, arguing that "a closed
network helps keeps costs low," chose not to provide out-of-network
coverage in most of New York State, including New York City (some plans
in the western part of New York State do offer such coverage).

Dr. Andrew D. Coates is an internist based in upstate New York who is
president of Physicians for a National Health Program (PNHP), an
organization that advocates for a single-payer health insurance system.
Coates, who was speaking during the interview for himself and not as a
representative of PNHP, agreed with the idea that the lack of
out-of-network options would enhance the ability of insurance companies
to engage in cost cutting, regardless of whether patients were harmed,
as, for example, in a push for doctors to see more and more patients
each day.

He thought that doctors were increasingly being put in an "ethical bind"
where their medical instincts might tell them in a particular instance
to recommend an out-of-network physician — the "one oncologist that you
can think of that should really evaluate what to do next" in the case of
a rare cancer — even as they knew that following that recommendation
would be financially ruinous for the patient.

More broadly, in Coates' view, the greater empowerment of insurance
companies was accelerating a turn towards "a corporate medical model
that threatens to squeeze the humanity out of our interaction with our
patients."

http://www.remappingdebate.org/article/out-network-coverage-new-york-we-left-it-insurers

****


Comment by Don McCanne

According to the Bloomberg Businessweek report, Ben Rosenthal and reader
John Alexander purchased the highest tier plans available - platinum
plans - to ensure that they would have coverage for their current
physicians and hospitals. No way. Insurers have pushed the perversity of
narrow network plans all the way to the top.

Before Barack Obama was even nominated, the Democratic strategists had
already decided that "Choice" would be a campaign slogan to market
health care reform. Some of us protested that Celinda Lake and Herndon
Alliance were pushing "choice of private health plans" when what the
Democrats should have been advocating was "choice of physicians and
hospitals." It is clear which faction won this debate, as single payer
supporters had the door slammed on them.

But look at the consequences. We were promised that we would have our
choice of any plan we wanted with benefits as rich as desired, and with
a selection of any health care providers we preferred. We could choose
our doctors and our hospitals. But what happened?

So they did set up four levels of plans that we could choose from, plus
a fifth catastrophic plan as an option for younger individuals. So we
could buy a cheap bronze plan that would cover an average of 60 percent
of our health care costs, 70 percent for silver, 80 percent for gold,
all the way up to an expensive platinum plan that would cover 90 percent
of costs. But there would be only negligible differences in the benefits
since all plans had to cover the same ten categories of benefits, though
some variation within each category is allowed as long as it had the
same actuarial value.

But the shocker is the networks that the insurers established. As the
AEI report indicates, for plans offered by the same insurer in the same
market, the provider networks were just as limited for the high end
platinum plans as they were for the cheapest bronze plans. If you want
your medical bills paid, you do not have a choice of physicians and
hospitals. You have to stay in network. Typically seventy percent of the
providers are outside of the narrow network plans offered through the
exchanges.

The Remapping Debate report reveals a further complication. Previously
plans were available that provided reduced payments for care obtained
out of network, with the patient paying a greater share of the costs.
Now in areas such as New York City, none of these plans are available
through the exchanges. You must stay in network or pay the full bill.

According to the McKinsey report, in some markets plans are available
with broader networks, but these are less prevalent and declining in
availability, and they are exorbitantly expensive. They will likely be
subject to the death spiral since most markets do not have enough super
wealthy individuals to maintain a vibrant market of broad network plans.
The super wealthy then will simply pay their own bills.

So the Democrats traded off our choice of physicians and hospitals for a
choice of deductibles and copayments, as the insurers took away the
choices that we actually wanted. The narrow and ultra-narrow networks
were a decision of the insurers, not us. We are getting what they want
rather than what we want, simply because the Affordable care Act was
designed to leave the insurers in charge.

As we've said before, all of this would go away if only we would enact a
single payer national health program. As PNHP president Andy Coates
says, physicians are placed in an "ethical bind" as they practice under
"a corporate medical model that threatens to squeeze the humanity out of
our interaction with our patients."

Thursday, March 20, 2014

Fwd: qotd: Got cancer? Don't buy a plan in our network.

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-------- Original Message --------
Subject: qotd: Got cancer? Don't buy a plan in our network.
Date: Thu, 20 Mar 2014 14:14:06 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Associated Press
March 19,2014
Health Law Concerns for Cancer Centers
By Ricardo Alonso-Zaldivar

Cancer patients relieved that they can get insurance coverage because of
the new health care law may be disappointed to learn that some the
nation's best cancer hospitals are off-limits.

An Associated Press survey found examples coast to coast. Seattle Cancer
Care Alliance is excluded by five out of eight insurers in Washington
state's insurance exchange. MD Anderson Cancer Center says it's in less
than half of the plans in the Houston area. Memorial Sloan-Kettering is
included by two of nine insurers in New York City and has out-of-network
agreements with two more.

In all, only four of 19 nationally recognized comprehensive cancer
centers that responded to AP's survey (members of the National
Comprehensive Cancer Network) said patients have access through all the
insurance companies in their state exchange.

Not too long ago, insurance companies would have been vying to offer
access to renowned cancer centers, said Dan Mendelson, CEO of the market
research firm Avalere Health. Now the focus is on costs.

"This is a marked deterioration of access to the premier cancer centers
for people who are signing up for these plans," Mendelson said.

Those patients may not be able get the most advanced treatment,
including clinical trials of new medications.

And there's another problem: It's not easy for consumers shopping online
in the new insurance markets to tell whether top-level institutions are
included in a plan. That takes additional digging by the people applying.

To keep premiums low, insurers have designed narrow networks of
hospitals and doctors. The government-subsidized private plans on the
exchanges typically offer less choice than Medicare or employer plans.

By not including a top cancer center an insurer can cut costs. It may
also shield itself from risk, delivering an implicit message to cancer
survivors or people with a strong family history of the disease that
they should look elsewhere.

For now, the issue seems to be limited to the new insurance exchanges.
But it could become a concern for Americans with job-based coverage too
if employers turn to narrow networks.

In a statement, Anthem said its network was based on research involving
thousands of consumers and businesses. "What we learned was that people
are willing to make trade-offs in order to have access to affordable
health care," the company said. "Our provider networks reflect this."

http://hosted.ap.org/dynamic/stories/U/US_HEALTH_OVERHAUL_TOP_CANCER_CENTERS

Members of the National Comprehensive Cancer Network
(http://www.nccn.org/members/network.asp)

****

CMS
March 14, 2014
2015 Letter to Issuers in the Federally-facilitated Marketplaces

Section 3. Network Adequacy

Pursuant to 45 C.F.R. 156.230(a)(2), an issuer of a QHP that has a
provider network must maintain a network that is sufficient in number
and types of providers… to assure that all services will be accessible
to enrollees without unreasonable delay. All issuers applying for QHP
certification will need to attest that they meet this standard as part
of the certification/recertification process.

CMS will assess provider networks using a "reasonable access" standard,
and will identify networks that fail to provide access without
unreasonable delay as required by 45 C.F.R. 156.230(a)(2).

If CMS determines that an issuer's network is inadequate under the
reasonable access review standard, CMS will notify the issuer of the
identified problem area(s) and will consider the issuer's response in
assessing whether the issuer has met the regulatory requirement and
prior to making the certification or recertification determination.

http://www.cms.gov/CCIIO/Resources/Regulations-and-Guidance/Downloads/2015-final-issuer-letter-3-14-2014.pdf

****

KFF.org
February 26, 2014
Kaiser Health Tracking Poll: February 2014
By Liz Hamel, Jamie Firth and Mollyann Brodie

The latest Kaiser Health Tracking Poll finds that, in general, the
public leans towards more expensive plans with broader networks. About
half (51 percent) say they would rather have a plan that costs more
money but allows them to see a broader range of doctors and hospitals,
while just under four in ten (37 percent) prefer a plan that is less
expensive but allows them to visit a more limited range of providers.
While older individuals and those with higher incomes exhibit a clearer
preference for more expensive plans with broader networks, younger
adults and those with lower incomes are more evenly divided in their
preferences. But those who are either uninsured or currently purchase
their own coverage – a group that is most likely to be in a position to
take advantage of new coverage options under the ACA – are more likely
to prefer less costly narrow network plans over more expensive plans
with broader networks (54 percent versus 35 percent). Those who
currently get their insurance through an employer (and are more
protected from the cost of coverage) have the opposite preference: 55
percent prefer a more expensive plan with a broader network, while 34
percent would rather have a cheaper narrow network plan.

Those who prefer narrow network plans may be less likely to prefer them
if it means they can't see their usual providers. When those who prefer
a less costly narrow network plan are presented with the possibility
that they would not be able to visit the doctors and hospitals they
normally use, the share who continue to prefer this option drops from 37
percent to 23 percent among the public overall, and from 54 percent to
35 percent among the uninsured and those who buy their own insurance.

On the other hand, when those who initially prefer a more expensive plan
with a broader network are told that they could save up to 25 percent on
their health care costs, the share continuing to prefer the more
expensive option drops from 51 percent to 37 percent among the public
overall, and from 35 percent to 22 percent among those the uninsured and
those with non-group coverage.

http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-february-2014/

****


Comment by Don McCanne

For decades we have been hearing heartrending stories of children and
adults under 65 who develop cancer but were uninsured. For those of us
striving for a comprehensive health care program for everyone, there
could not be a greater motivating force than the desire to eliminate
forever the twin tragedies of impaired access to care and personal
financial ruin for these unfortunate cancer victims.

The Affordable Care Act brought us expanded access to private insurance
plans with incentives for the insurers to provide plan innovations to
help slow spending on health care. Although plans already were using
limited networks to leverage lower prices from the providers, the degree
to which they would further narrow networks was not expected, except
perhaps by the cynics amongst us.

But the insurers have no shame. Cancer management is expensive. What
better place to restrict access could there be than to remove most
members of the National Comprehensive Cancer Network from many of their
insurance networks. Only four of nineteen of these centers are included
in all exchange plan networks within their respective states.

CMS tells us that they will use a "reasonable access" standard when the
plans are recertified for the federal exchanges next year. This is a
relative rather than an absolute standard. They have no intention of
opening up insurer networks to all comers. That would defeat the
insurance innovation of controlling costs by blocking access to
out-of-network providers, especially the expensive ones such as the
members of the National Comprehensive Cancer Network.

The latest Kaiser tracking poll is of concern since it shows that
lower-income and uninsured people will select the plans with more
restricted networks simply because the premiums are lower. No
centers-of-excellence cancer care for them.

Although insurers are prohibited from denying coverage, just think of
the advantage they would have in avoiding adverse selection by being
able to tell those patients who have cancer that they really don't want
to buy the plans they offer since the nation's noted cancer institutions
are not covered. They can do the cancer victim a favor by sending her to
a competitor. Then they can retreat into their headquarters to devise
yet more insurance innovations that work this well.

A single payer national health program would not have networks. Patients
could go anywhere. With an improved primary care infrastructure, they
would receive assistance in obtaining the best care for their medical
condition. For those with cancer, there would be no private insurers
profiting off of discount cancer care, though the single payer system
would take care to see that the services are priced right for the
benefit of us taxpayers who would be financing our health care system.

Wednesday, March 19, 2014

Fwd: qotd: "Medical home" proponents should focus on specific services for specific patients

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-------- Original Message --------
Subject: qotd: "Medical home" proponents should focus on specific
services for specific patients
Date: Wed, 19 Mar 2014 11:29:35 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Commonwealth Fund Blog
February 25, 2014
Medical Home: An Evolving Model of Primary Care
By Melinda K. Abrams

Today, the Journal of the American Medical Association (JAMA) released a
study, cofunded by The Commonwealth Fund, evaluating a three-year
medical home pilot in Pennsylvania. The study, led by RAND's Mark
Friedberg and colleagues, found the program was not associated with
significant improvements in quality of care or cost reductions. ….

While some may be ready to hand medical homes a failing grade, the
study's findings underscore what we already knew about this team-based
model of primary care: we need to continue to improve how care is
delivered, how providers are paid, and how the model is implemented in
different settings.

Since the Pennsylvania initiative was launched in 2008, we have learned
more about how best to implement an effective patient-centered medical
home. For example, it's become clear that the payment model needs to
reward cost savings as well as quality improvement. ….

In addition, evidence suggests that sites targeting patients with
complex medical conditions are more likely to see an impact on outcomes
and utilization than those serving patients with more routine needs. ….

But this study also raises questions about whether recognition criteria
used by NCQA and other accrediting organizations need to better reflect
meaningful practice transformation….

http://www.commonwealthfund.org/Blog/2014/Feb/Medical-Homes-Evolving-Primary-Care.aspx

==

Comment by Kip Sullivan, JD

The February 25 edition of JAMA published a study of "patient-centered
medical homes" (PCMH) by Mark Friedberg et al. The authors reported that
PCMHs had no effect on costs and almost no effect on quality (PCMHs
outperformed the control clinics on only one of 11 quality measures). In
fact, it appears that PCMHs raised costs when the costs associated with
setting up PCMHs and rewarding PCMH doctors is taken into account.

The PCMH may not survive much longer if research continues to show that
it cannot cut costs. The loss of the "medical home" metaphor will be
inconsequential, but if the termination of the PCMH experiment sets back
the campaign to strengthen the primary care sector, that will be a
significant loss. To avoid that outcome, PCMH proponents should cease
hyping the PCMH as a cost containment device applicable to entire
"populations" and instead focus on specific services for specific patients.

Cutting costs has always been one of the primary goals of PCMH
advocates. For private insurers, it is not merely a goal – it is a
precondition. Unless it is ordered to do otherwise by state legislatures
or Congress, the American insurance industry will not, over the long
haul, subsidize clinics to provide "home" services if those services do
not reduce the industry's net costs – their subsidies to PCMHs plus
their expenditures on claims. Nor will clinics certified as PCMHs
provide, over the long term, the services PCMHs are expected to provide
if insurers refuse to compensate them for those services. And if
insurers and PCMHs refuse to pay for those services, it is extremely
unlikely patients can be persuaded to pay for them.

The "medical home" label was originally coined to refer to clinics which
held all the records of children with special needs. But in 2007 the
concept was greatly expanded by the American Academy of Family
Physicians and three other primary care specialty groups and promoted as
a means to bring more resources into the entire primary care sector
while simultaneously cutting costs
http://www.aafp.org/dam/AAFP/documents/practice_management/pcmh/initiatives/PCMHJoint.pdf.
As Robert Berenson et al. put it in a 2008 paper, "[T]he medical home
can be viewed as an alternative way to recognize and support primary
care activities, particularly those that are not considered to be part
of evaluation and management service codes...."
http://content.healthaffairs.org/content/27/5/1219.abstract As Ed Wagner
and other PCMH advocates put it in a 2012 paper for the Commonwealth
Fund, "Among the experts, stakeholders, and patients consulted for this
report, there was broad agreement that … sustaining the PCMH model and
making the case for increased primary care payments hinge on success in
reducing health care costs."
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2012/Feb/1582_Wagner_guiding_transformation_patientcentered_med_home_v2.pdf

Promoting the "medical home" as a cost-containment tool rather than
simply calling for more resources for primary care may turn out to have
been a mistake. It is becoming increasingly apparent that the
cost-cutting prowess of the "home" was vastly exaggerated by its
proponents. It should have been described only as an approach or model
that might cut costs if applied to specific categories of chronically
ill patients. Thanks to research like the paper by Friedberg et al.,
that realization seems to be dawning on PCMH advocates. The comment on
the Commonwealth Fund blog quoted above is one example. An editorial
accompanying the JAMA paper, aptly entitled "One size does not fit all,"
is another. Even the ever-optimistic Patient-Centered Primary Care
Collaborative (which last year added Liz Fowler to its board
http://www.pcpcc.org/2013/07/23/liz-fowler-jill-hummel-hal-lawrence-and-adrienne-white-faines-join-pcpcc-board-directors)
said of the JAMA paper, "There was no targeting and/or analysis of
chronically ill patients."
http://www.pcpcc.org/2014/02/26/pcpcc-leadership-responds-jama-article-medical-home-pilot-study

The "medical home" movement would be well advised to stop exaggerating
the cost-containment powers of the PCMH and instead call for
experimentation and research on specific services for specific types of
chronically ill patients. Let me offer one example suggested by the
Friedberg paper. The PCMH model studied by Friedberg et al. focused on
diabetes care – six of the 11 quality measures measured some aspect of
diabetes treatment. The one measure at which the PCMH clinics excelled
turned out to be a diabetes measure (kidney exams). How did the PCMH
clinics achieve this laudable outcome? We don't know, but it is
reasonable to infer that the high percentage of diabetes measures in the
quality measurement set caused the clinics to "teach to the test" – to
concentrate resources on diabetes patients, possibly at the expense of
patients without diabetes. Did they use some or all of the diabetes
disease management techniques that have been shown to improve the health
of diabetics and pre-diabetics? We don't know.

If instead of testing the impossibly amorphous, one-size-fits-all "home"
concept, the PCMH clinics had tested their ability to improve the health
of diabetics with specific treatments and interventions, we might now be
reading a paper with useful information about what treatments work for
diabetics and whether those treatments cost more to deliver than they
saved in future medical costs. Instead we are left to scratch our heads
about why the latest over-hyped managed care fad with the saccharine
name isn't working.

The AAFP and other proponents of the "medical home" should never have
burdened the concept with the expectation of cost containment. If they
were serious about cost containment, they should have endorsed
single-payer legislation. If they were serious about strengthening the
primary care sector, they should have called for more money for primary
care, period.

Tuesday, March 18, 2014

Fwd: qotd: Stuck out-of-network and vulnerable

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-------- Original Message --------
Subject: qotd: Stuck out-of-network and vulnerable
Date: Tue, 18 Mar 2014 11:08:10 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Kaiser Health News
March 18, 2014
Warning: Opting Out Of Your Insurance Plan's Provider Network Is Risky
By Michelle Andrews

Many plans sold on the health insurance marketplaces offer a tradeoff:
lower premiums in exchange for limited networks of providers. But
consumers who opt for a narrow network plan with the idea that they'll
go out of network when necessary may be taking a big financial risk.

The health law generally places limits on how much consumers can be
required to pay out of pocket for medical care (not including premiums).
In 2014, the limit for an individual plan is $6,350 and for a family
plan, $12,700. But those limits apply only to care provided by doctors
and hospitals in a plan's provider network. There may be a separate
out-of-pocket maximum for services provided out of network in
marketplace plans, or no cap at all.

Similarly, the health law requires that preventive care such as
vaccines, cancer screenings and annual checkups be covered at no cost to
consumers in most health plans. If someone uses an out-of-network
provider, however, they can be charged.

Going out of network opens the door to higher costs in other ways as
well. Plans may require patients to pay a higher copayment or
coinsurance for an out-of-network provider. In addition, since the
doctors, hospitals and other providers are not under contract with the
insurance company, in many states those providers may bill patients for
any charges not covered by the insurance, a practice known as "balance
billing." The contracts signed by providers who join plan networks
generally contain provisions that prohibit them from balance billing
enrollees.

Plans sold on the marketplace are divided into four levels based on the
amount of consumer cost sharing required. On average, a bronze plan pays
for 60 percent of covered medical services, a silver plan pays for 70
percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But
those percentages don't take any out-of-network care into account.

A McKinsey & Co. analysis of 120 silver-level exchange plans found that
70 percent were narrow network plans, in which at least 30 percent of
the area's largest hospitals are not in the plan, or ultra narrow
network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that
don't cover any out-of-network care except for emergency services.
According to the analysis by Breakaway Policy Strategies, roughly a
third of mid-level silver plans are of this type, typically leaving
consumers on the hook for the entire bill if they get care from an
out-of-network provider.

The health law does provide protection for consumers when they receive
emergency care from a hospital that's not in their provider's network.
In such instances, health plans can't charge consumers higher
coinsurance or copayments.

However, patients placed on observation status or admitted to the
out-of-network hospital from the emergency department are no longer
shielded from higher out-of-pocket costs.

"Once the patient is stabilized, the patient will be responsible for
whatever the insurer doesn't pay for that observation or admittance,"
says Jeffrey Bettinger, an emergency physician who is chairman of the
reimbursement committee of the American College of Emergency Physicians.

Whichever type of plan they choose, the onus is on consumers to dig into
the details and make sure they understand what they're signing up for.
There's a tremendous amount of variability in exchange plans, even among
silver level plans, says Richard Smith, executive vice president at
Breakaway Policy Strategies.

"I don't see a lot of standardization," he says. "Consumers need to be
really cognizant. There are design features of these plans that
consumers need to be aware of."

http://www.kaiserhealthnews.org/Stories/2014/March/18/Michelle-Andrews-opting-out-insurer-provider-network-risky.aspx


Comment by Don McCanne

Most people who have been paying any attention at all are quite aware
that health plans inside and outside of the exchanges limit coverage to
physicians and hospitals within their contracted networks. Although some
plans may also offer limited coverage outside of the networks, it is
less clear as to the extent and adequacy of that coverage. This article
helps to clarify that issue by showing how muddled the coverage is.

Some of the traps include care provided outside of HMOs, care provided
after an emergency patient is stabilized, free preventive services that
may not be free outside of the network, services provided within network
that are not benefits of the specific plan selected, and so forth. What
is particularly treacherous is that, not only do you usually have to pay
in full for these services, but your payments may not apply to your
maximum out-of-pocket expenses, which can be unlimited out-of-network.
The ACA promise that out-of-pocket expenses will be capped for the year
($6,350 for an individual and $12,700 for a family) comes from the same
book of promises that gave us "you can keep your plan if you like it."
It is possible to end up with expenses over six figures. That is quite a
whack for the person who was trying to do the right thing by buying a
qualified insurance plan.

The precise out-of-network coverage depends on the specifications of the
plan selected, and there are very few standards with which the plans
must comply. So how do you select the right plan?

When people purchase their plans, they usually look first at the
premium. Then they look at the deductibles and then the copayments or
coinsurance. Usually, when assisted by a plan navigator or equivalent,
they will also look at the tax credits for the premiums and the
subsidies for cost sharing. Since many benefit from these they often
select a silver plan because that is the only tier that includes
cost-sharing subsidies.

The next step is to check the list of providers to see if your
physician(s) or hospital(s) are on the list. This is where it becomes
more tricky since those lists are often difficult to access, and they
can be quite unreliable. Even physicians can be confused since they may
be included on an insurer's plan outside of the exchanges, but excluded
from the exchange plans, and yet they may not be aware of the exclusion.

Finally, just try to find out the precise rules for coverage of care
obtained outside of the network. Since there are very few standards, it
is important to know this. The various insurers may approach such
charges quite differently. You could end up with only modest additional
expenses, but it is not too difficult imagining a six-figure bill when
you are admitted to an out-of-network hospital. The insurer may cover
the charges in the emergency room, but once the stabilized patient is
admitted, she may well be on her own for all additional charges.

Think of how administratively complex the private insurers have already
made our system. Then think of the administrative excesses that arise
just from handling the muddled out-of-network care. The insurers are
forcing upon us even more of their primary product - administrative
services - while evading the very purpose of health care coverage by not
paying for medical services that the patient needs.

If we had a single payer national health program with first dollar
coverage (like many other nations with much lower health care costs)
then this out-of-network nonsense would go away. What is really
perplexing is why haven't our people demanded this before now? Don't
facts matter?

In fairness, when we, as experts, think of how much effort we have to
put in just to understand these issues, it is no wonder the the insurers
and the rest of the medical-industrial complex have been so successful
in bamboozling the public at large. We can use the political process to
overcome this, but it would require a massive effort. After a couple of
decades of working on this, I don't see it happening. Prove me wrong.

Saturday, March 15, 2014

Fwd: qotd: Canada's Dr. Danielle Martin educates Sen. Richard Burr on single payer

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-------- Original Message --------
Subject: qotd: Canada's Dr. Danielle Martin educates Sen. Richard Burr
on single payer
Date: Sat, 15 Mar 2014 11:46:43 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



YouTube
March 12, 2014
Health Care: U.S. vs. Canada

On March 11, 2014, several authorities on single payer health care
systems of other nations testified before a committee of the United
States Senate, chaired by Sen. Bernie Sanders. The hearing was not only
the topic of a recent Quote of the Day (March 12), it also has been
covered extensively in the media and on the Internet throughout the
United States and Canada.

It was the responses of Dr. Danielle Martin of Canada to the questions
from Committee Ranking Member Sen. Richard Burr, that caused this story
to go viral. For those who missed it, the 7 minute segment that includes
the exchange between Dr. Martin and Sen. Burr can be viewed at this
YouTube link:

http://www.youtube.com/watch?v=iYOf6hXGx6M



****

You can read more about this exchange by Googling "Danielle Martin."
Some of the other coverage:

National Post: "Toronto doctor smacks down U.S. Senate question on
Canadian waitlist deaths"
http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/

Los Angeles Times: "Watch an expert teach a smug U.S. senator about
Canadian healthcare"
http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story

Huffington Post: "Watch This Doctor Totally School An Anti-Obamacare
Senator On Health Care"
http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html

Huffington Post Canada: "Canadian Doctor Gives U.S. Senator A Clinic On
Public Health Care"
http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html

CBC.ca (audio): "Canadian doctor schools U.S. Senator on public health care"
http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/

MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host):
http://www.msnbc.com/rachel-maddow-show

The Maddow Blog: "Martin 1, Burr 0"
http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break

Salon: "Canadian doctor makes anti-Obamacare senator look like a buffoon"
http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/

Toronto Star: "Toronto doctor smacks down U.S. senators' myths about
Canadian health care"
http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html

Canada.com: "Watch: Canadian doctor schools American senator on health care"
http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/

Huffington Post Canada: "Republicans Ruin Health Care By Ignoring Jesus
(And Canada)"
http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html

Well, you get the point.


For those interested in viewing the entire hearing (1 hour, 45 minutes),
or wish to download witness statements:

http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Friday, March 14, 2014

Fwd: qotd: Half will have change of eligibility for Medicaid or subsidies within one year

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-------- Original Message --------
Subject: qotd: Half will have change of eligibility for Medicaid or
subsidies within one year
Date: Fri, 14 Mar 2014 12:39:57 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs
April 2014 (online March 12, 2014)
Medicaid And Marketplace Eligibility Changes Will Occur Often In All
States; Policy Options Can Ease Impact
By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum

Beginning January 1, 2014, the Affordable Care Act (ACA) established two
pathways to health insurance for nonelderly US citizens and legal
residents. The first was an expansion of Medicaid coverage for people
with annual incomes of up to 138 percent of the federal poverty level in
states that elected to expand their programs. The second pathway was
subsidizing private coverage purchased via health insurance Marketplaces
for people with incomes of 138–400 percent of poverty who do not have an
offer of affordable coverage through an employer. The pathways are
designed to work in tandem, but a major challenge is how to promote
continuity of coverage and health care for people when their incomes and
life circumstances cause them to transition between Medicaid and
subsidized private coverage.

In states that opt out of the ACA's Medicaid expansion, changes in
income or family circumstance will lead many people to lose coverage
entirely unless they qualify for coverage under one of the traditional
categories of Medicaid eligibility: pregnancy, disability, or being the
impoverished parent of a minor child. A less stark problem that presents
a different set of challenges will occur in states that do expand
Medicaid: the potential for moving between Medicaid and Marketplace
coverage.

Both of these types of "churning"—loss of coverage and frequent
transitions in the source of coverage—can cause difficulties. The total
loss of coverage raises the most serious problems in terms of access to
care, but frequent transitions across coverage pathways also raise
important issues for beneficiaries, health plans, providers, and policy
makers. From one year to the next or during any given year, many
individuals and families will experience changes in eligibility either
for Medicaid or for Marketplace coverage. These eligibility changes
could lead to both gaps in coverage and disruptions in the continuity of
care, because people might have to find new providers or change their
existing health treatments if their new insurance plan uses a different
provider network or covers different services than their old plan did.

Previous research has estimated that approximately half of low-income
adults might experience a change in income or family circumstances
leading them to transition from Medicaid to Marketplace coverage (or
vice versa) each year.

From the Discussion

We estimated that approximately half (plus or minus 5 percentage points)
of adults likely to be eligible for Medicaid or subsidized Marketplace
coverage will experience an eligibility change within twelve months.

It is important to recognize that the eligibility changes we have
analyzed are the result of an effort to expand pathways to affordable
coverage for all Americans. Churning has often been used to describe the
negative outcome of moving into and out of insurance coverage and
becoming uninsured. In contrast, we are discussing changes that are a
by-product of a system that allows for transitions among insurance
pathways. These transitions increase the risks of disrupting care
continuity and of having short gaps in coverage. But they represent a
different (and less problematic) form of churning than that between
having Medicaid or Marketplace coverage and being uninsured.

However, when low-income adults in states that opt not to expand their
Medicaid programs experience a loss of income that drops them below 100
percent of poverty, most will not be eligible for subsidized coverage in
the Marketplace or for Medicaid. Most nonexpansion states restrict
Medicaid eligibility for adults to pregnant women, certain low-income
adults with disabilities, and parents of minor children with incomes of
no more than 35 percent of poverty on average. In other words, most
adults who lose Marketplace subsidies in nonexpanding states will become
uninsured, as has traditionally happened to adults who lose Medicaid
eligibility.

Policy Implications

A number of policies have recently been proposed to mitigate the effects
of churning between Medicaid and Marketplace coverage, and state policy
makers should consider them in the light of our findings.

One option is for states to adopt twelve-month continuous eligibility
periods in Medicaid as a means of overcoming the churning effects of
periodic income fluctuations

A second, more incremental option offered in CMS's 2012 regulations
allows states to assess people's ongoing eligibility for Medicaid using
projected annual income instead of current monthly income.

A third option for states is to use Medicaid funds to purchase coverage
in qualified health plans in the Marketplace for people with incomes
below 138 percent of poverty.

A fourth approach is the Basic Health Program, an option under the ACA
that enables states to combine their Medicaid expansions with
Marketplace subsidies into a single program for individuals and families
with incomes of up to 200 percent of poverty.

A fifth option relates to how and when income changes are verified.

Finally, a state option that combines enrollment and marketing
strategies is to encourage certified Medicaid managed care plans to
enter state Marketplaces.

http://content.healthaffairs.org/content/early/2014/03/10/hlthaff.2013.1023.abstract

****


Comment by Don McCanne

The Affordable Care Act (ACA) compounded and locked into place our
highly fragmented, multi-payer method of financing health care. It is a
system that makes churning inevitable - moving in and out of various
plans or having no coverage at all, simply because program eligibility
varies depending on each individual's circumstances which often are in
an intermittent state of flux.

As if there was not already enough instability with employer-sponsored
and individual market plans, this study shows that under the two major
expansions of ACA, "approximately half of adults likely to be eligible
for Medicaid or subsidized Marketplace coverage will experience an
eligibility change within twelve months." Half in just the first year
alone. What after that?

Eligibility change is highly disruptive to care. It changes the amounts
that the individual or family will have to pay for premiums, cost
sharing, and non-covered services. It changes the provider networks that
vary under different plans. It can disrupt treatment programs. It can
result in gaps in coverage or no coverage at all. As is typical with
Medicaid, it can even change the willingness of physicians to accept the
individual or family as patients.

And that line about keeping the coverage you have if you want it? Within
one year, half will have a change in their eligibility. And the
recommendations of the authors will only tweak the instability, but the
fundamental problem will not be corrected. It is the ACA model that is
irreparably flawed.

Unless we change our model of financing, instability and disruption will
be the norm, not only because of shifting eligibility but also because
plans obtained through employment or in the market are undergoing
dramatic changes - even if less transparent - that will impact all of us
with greater cost sharing, narrower networks, and other changes that
none of us want. Do Americans really accept this mess as our preferred
option for health care financing?

Change to a single payer national health program and this all goes away.

Wednesday, March 12, 2014

Fwd: qotd: Senate committee on single payer lessons for the U.S.

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-------- Original Message --------
Subject: qotd: Senate committee on single payer lessons for the U.S.
Date: Wed, 12 Mar 2014 13:15:49 -0700
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



United States Senate
Committee on Health, Education, Labor and Pensions (HELP)
Subcommittee on Primary Health and Aging
Chaired by Sen. Bernard Sanders
March 11, 2014
Subcommittee Hearing - Access and Cost: What the US Health Care System
Can Learn from Other Countries

Statement by
Tsung-Mei Cheng, LL.B., M.A.
Health Policy Research Analyst
Woodrow Wilson School of Public and International Affairs, Princeton
University

Today's hearing is focused on "international single payer health system
models that provide universal coverage of health care." I will tailor my
remarks according to the three sub-themes the Committee wishes to
explore, namely:

* Primary care access in single payer systems
* Health care costs in single payer systems, and
* Cross-country comparisons of health outcomes

Before proceeding with the Committee's agenda in more detail, however, I
would like to provide the Committee with a summary of my main points:

1. If equity and social solidarity in access to health care and
financing health care were fundamental goals of a health care system,
the single payer system provides an ideal platform for achieving these
goals.

2. Single-payer systems typically are financed by general- or payroll
taxes in a way that tailors the individual's or family's contribution to
health-care financing to their ability to pay, rather than to their
health status, which until this year has long been the practice in the
individual health insurance market in the U.S.

3. These systems protect individual households from financial ruin due
to medical bills.

4. Single-payer health systems typically afford patients free choice of
health-care provider, albeit at the expense of not having a freedom of
choice among different health insurers. Remarkably, in the U.S.
households have some freedom of choice of health insurers – to the
extent their employer offers them choice – but most Americans are
confined to networks of providers for their insurance policy. In other
words, Americans appear to have traded freedom of choice among providers
for the sake of choice among insurers.

5. In single-payer systems "money follows the patient." Therefore
providers of health care must and do compete for patients on the basis
of quality and patient satisfaction, but not price.

6. In a single payer health insurance system, health insurance is fully
portable from job to job and into unemployment status and retirement.
The "job-lock" phenomenon prevalent in the US is unknown in those
systems, contributing to labor-market efficiency.

7. Because all funds to providers of health care in a single-payer
system flow from one payer, it is relatively easy to control total
health spending in such systems. Indeed, total national health spending
as a percent of GDP in countries with single-payer systems is lower than
it tends to be in non-single-payer health systems. This does not mean
providers are left without a voice. Provider inputs are part of the
formal negotiations over health-care budgets.

8. For the most part, single-payer systems achieve their cost control by
virtue of the monopsonistic market power they enjoy vis a vis providers
of health care. It is a countervailing power that the highly fragmented
U.S. health-insurance system lacks vis a vis providers.

9. As part of their effort to control total health spending, however,
and to avoid the waste of excess capacity that easily develops in health
care, some single-payer systems (the UK and Canada) put constraints on
the physical capacity of their health system (number of inpatients beds,
MRI scanners, etc). That approach can lead to rationing by the queue.
The alternative to rationing by such administrative devices, of course,
is rationing by price and ability to pay, an approach used by design or
by default in the United States. Rationing by price or by non-price
mechanism are just alternative forms of rationing.

10. A single-payer system is an ideal platform for a uniform electronic
health information system of the sort, for example, used by our Veterans
Administration health system (a single-payer system in its own right).
There is a common nomenclature which enables 100% electronic billing and
claims processing, thus yielding significant savings in administrative
costs.

11. Because they conveniently capture information on all health-care
transactions, single-payer systems provide a data base that can be used
for quality measurement, monitoring and improvement, and also for more
basic research on what drives health spending and what clinical
treatments works and does not work in health care. It enables evidence
based medicine and the tracking of efficacy and safety of new drugs and
devices once they are introduced after approval by government based on
results of clinical trials.

Statement of Tsung-Mei Cheng (28 pages):
http://www.help.senate.gov/imo/media/doc/Cheng.pdf

Video of the hearing and links to statements of all participants:
http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

****


Comment by Don McCanne

Sen. Bernie Sanders chaired a Senate committee hearing on what the
health care system in the United States can learn from other countries.
Tsung-Mei Cheng provided an excellent overview of single payer and of
the sharp contrasts between the United States and other nations. Her 28
page statement is well worth downloading to use as an information
resource in educating others about single payer.

Other informative presentations included those of Victor Rodwin on
France, Ching-Chuan Yeh on Taiwan, Danielle Martin on Canada, and Jakob
Kjellberg on Denmark. Even the presentations from the other side by
Sally Pipes and David Hogberg were helpful in that they showed how silly
(sadly) their views were when contrasted with a group of experts who
understand well how systems based on solidarity work. If you can find
the time, viewing the entire video (1 hour & 46 minutes) and reading the
statements would be well worth the effort (link above).

If you don't have the time, at least view this 4 minute YouTube video of
clips from the hearing:
https://www.youtube.com/watch?v=9WdqtPLRc1A