qotd: AHIP mischaracterizes NICE alcohol screening recommendations

America's Health Insurance Plans (AHIP)

June 2, 2010

British Doctors Must Now Ask: Tell Us How Much You Drink

(Source - Rebecca Smith, The Daily Telegraph)

Under new guidelines set by the National Institute for Health and Clinical Excellence (NICE), British healthcare providers are required to inquire about their patients' drinking habits as a means to curb the nation's problem with drinking. NICE recommends that doctors and pharmacists alike gauge patient-consumption tendencies through a series of "alcohol screening" questions - the line of interrogation including no less than 10 questions.

http://www.ahiphiwire.org/International/News/Default.aspx?doc_id=589183&utm_source=6/2/2010

And...

National Institute for Health and Clinical Excellence (NICE)

PH24 Alcohol use disorders: preventing harmful drinking: guidance

Recommendation 9: screening adults

Where screening everyone is not feasible or practicable, NHS professionals should focus on groups that may be at an increased risk of harm from alcohol and those with an alcohol-related condition. This includes people:

− with relevant physical conditions (such as hypertension and gastrointestinal or liver disorders)

− with relevant mental health problems (such as anxiety, depression or other mood disorders)

− who have been assaulted

− at risk of self-harm

− who regularly experience accidents or minor traumas

− who regularly attend GUM clinics or repeatedly seek emergency contraception.

Full report (100 pages):

http://www.nice.org.uk/nicemedia/live/13001/48984/48984.pdf

The 10 questions used for screening (page 16 of 35 pages):

http://www.nice.org.uk/nicemedia/live/13001/49023/49023.pdf

About NICE: "NICE produces guidance on public health, health technologies and clinical practice."

http://www.nice.org.uk/aboutnice/whatwedo/what_we_do.jsp

Comment:  Great Britain's National Institute for Health and Clinical Excellence (NICE) produces guidance on public health, health technologies and clinical practice. Their efforts are directed at improving value in health care, especially reducing spending for ineffective or inappropriate services and products.

America's Health Insurance Plans (AHIP) has repeatedly called for government policies that would help control spending. You would think that AHIP would be supportive of the NICE concept, but by distributing today's release that falsely states, in essence, that British physicians are being required to invade the privacy of every one of their patients by submitting them to a questionnaire on alcohol use, it seems that AHIP is joining forces with the conservatives who have been condemning NICE as a program of socialistic government rationing. Nowhere in the 100 page NICE report does it state that universal alcohol screening is an absolute requirement. Also for a physician to discuss alcohol problems with a patient is no more an invasion of privacy than discussing any other factors that might influence the patient's health.

The good news is that the United States has taken a step forward by expanding the role of comparative effectiveness research (CER). Although it is unclear as to whether CER would have much impact on total health care spending, there is no question but that it will provide greater value in our health care.

If we really do care about attaining greater value then we need to expand NICE-like policies while eliminating the profound waste of the superfluous insurance industry represented by AHIP.

qotd: Dilemma of insuring seasonal agricultural workers

The Oregonian

May 29, 2010

Oregon agriculture industry sorts health care

By Harris Meyer

Unlike many agricultural employers, Ken Bailey of Orchard View Farms in The Dalles offers his 85 full-time workers health insurance. The orchard and packinghouse operator pays 80 percent of the premium for workers and their dependents. 

But like nearly all growers, Bailey's company does not offer coverage to the 600 to 700 seasonal workers it hires for about eight weeks each year to pick cherries and pears on its 2,080 acres. It's estimated that as few as 10 percent of farmworkers nationally have health insurance. 

Now, Bailey and other farmers in Oregon and Washington are nervous about the federal health reform law passed in March. It requires employers with 50 or more full-time equivalent workers to provide health coverage starting in 2014 or pay a $2,000 penalty per employee. Bailey, who favored health reform, said he's comfortable with that. Industry groups say most Pacific Northwest growers are too small to fall under that mandate. 

But the new law also may require larger farmers and packers like Bailey who meet the 50-employee threshold to offer insurance to seasonal workers or pay the penalty, depending on how the government writes the rules, according to the American Farm Bureau Federation in Washington, D.C. That would be a major new cost for growers already struggling with the bad economy and lower prices for their products. 

"It's almost impossible for individual growers to cover seasonals," Bailey said. "It depends on whether there is a reasonable program with a reasonable price." Farmers might even end up paying for coverage of undocumented workers, he said, since they have no reliable way of verifying their workers' legal status because so many documents -- even Social Security cards -- can be faked. 

For agricultural employers, though, the biggest concern is whether they'll be required to cover seasonal workers, whom Pacific Northwest growers depend on heavily for their labor-intensive fruit and vegetable crops. The law excludes seasonals -- defined as working 120 days or fewer in a calendar year -- from being counted toward the threshold of 50 full-time-equivalent employees that brings employers under the insurance mandate. But a new Congressional Research Service analysis says the law requires employers over that threshold to cover seasonals during the months they are working full-time or pay the penalty. 

The seasonal worker issue is just one of many uncertainties facing agricultural employers and workers as the complex new health care law is rolled out.

http://www.oregonlive.com/business/index.ssf/2010/05/oregon_ag_industry_sorts_healt.html

Comment:  This is yet another of the endless examples of how the Patient Protection and Affordable Care Act (PPACA) is so flawed that it cannot ever result in accomplishing the primary reform goal of covering everyone. Seasonal agricultural workers do not fit into a neat slot in the dysfunctional, fragmented financing system that President Obama and Congress have selected for us.

The first question we might ask is should all seasonal agricultural workers in the United States have the health care that they need without having to suffer potentially severe financial consequences? If you support cultural narcissism and reject social solidarity, then go away. You really wouldn't fit in with a group of people who believe that we should take care of each other, and our views are apt to only make you more angry.

Those who do believe that seasonal agricultural workers should have health care the year around, if they need it, understand how complex the rules will have to be to cover them with a system that includes an employer mandate, an individual mandate, and varying requirements based on previous, current and future employment, or unemployment, and based on the impact of vacillations in income as related to sliding-scale eligibility or ineligibility for various programs.

Just briefly touching on some of the policies inherent in PPACA: employers with over 50 full-time equivalent employees will have to purchase coverage for their seasonal employees or pay a $2000 penalty per employee, even though that may be a staggering bill because of a temporary ten-fold increase in the number of employees; since most seasonal employees are uninsured, moving in and out of coverage during the harvest season results in instability of coverage; many seasonal workers are undocumented and thus ineligible for purchase of plans in the exchanges, defeating the purpose of the individual mandate; seasonal workers might be able to obtain care through community health centers, though that depends on having clinics accessible and may mean that important specialized services may not be provided, and the mere existence of such clinics may not fulfill the mandate requirements anyway; though the workers and their families might be eligible for Medicaid on an income basis, that may conflict with the employer mandate; etc.

One of the structural problems is that this fragmented system attempts to assign an insurance product, whether employer-sponsored, privately purchased in the individual market, privately purchased in the exchange, provided by the government in the form of Medicaid, or provided as a safety-net function such as the community health centers, when the eligibility and ability to pay is highly variable between individuals and at different points in time. Fragmentation, disruptions, and voids in coverage are inevitable. We need to sever the individual link to a specific insurance product.

What would fix this would be a single payer national health program with automatic enrollment for everyone, financed separately though equitable tax policies. For purely ethical reasons, we can't accept the new status quo of the highly dysfunctional PPACA. We need to dump it and move on with an improved Medicare for everyone.

For the cultural narcissists who read this far, we would hope to enact a system that would ensure that you will always be able to have the health care that you need, but we would also use the tax system to prohibit you from being a free rider, just as the tax system prevents us from not paying our share of the wars that we oppose.

qotd: Anthem Blue Cross has racked up 479 enforcement actions

Payers and Providers

May 27, 2010

Anthem Big Outlier In DMHC Actions

Since the California Department of Managed Health Care (DMHC) began its regulatory mission a decade ago, it has levied nearly 1,200 enforcement actions against health plans, providers and other entities for violating state laws and regulations. The DMHC typically issues penalties for not responding to member grievances or failing to pay claims in a timely fashion.

Among the 170 organizations that have been penalized by the DMHC, Anthem Blue Cross of California stands alone.

The Indianapolis-based Anthem has racked up a remarkable 479 enforcement actions, or more than 40% of the statewide total, according to DMHC records. Some 275 of those actions have been levied against Anthem since early 2009 – including a $2.5 million fine the agency issued last November but has yet to publicize.

Anthem's overall number is more than quadruple the 102 enforcement actions levied against San Francisco-based Blue Shield of California, the second-largest total.

Anthem Blue Cross equated the number of enforcement actions to its size: "As the state's largest health benefits company serving more than 8 million people in California each year, it is not surprising that we might have the largest number of inquiries from the DMHC," the insurer said in a prepared statement. Yet the only insurer of similar size to Anthem in California, Oakland-based Kaiser Foundation Health Plan, has received just 84 enforcement actions from the DMHC. It has 6.7 million enrollees statewide.

"The failure to timely respond to member grievances appears to be due to the lack of administrative capacity," stated (DMHC spokeswoman Lynne Randolph).

http://www.payersandproviders.com/publications/pp527.pdf

Comment:  A unique characteristic of the U.S. health care system is the profound administrative waste, in a large part due to the administrative excesses of the private insurers and the administrative burden that they place on the providers of health care. The administrative component of just the private insurers alone is so large that Congress has codified the policy that 15 to 20 percent of health insurance premiums will be allocated for the insurers to use for their own intrinsic administrative services.

Currently outrage is being expressed over the very high insurance premium increases which the insurers attribute to increased health care costs. But the insurers are retaining the same high percentages of these ever higher premiums even though their marginal costs for administrative services should not be increasing at the same rate as health care prices. The increased spending on health care has provided a windfall for the private insurers.

So what are we getting for the massive amount of dollars being retained by the private insurers? Administrative services, and in great excesses at that. Yet why has WellPoint's Anthem Blue Cross had so many enforcement actions levied against it? As the Department of Managed Care's spokeswoman states, "The failure to timely respond to member grievances appears to be due to the lack of administrative capacity."

Lack of administrative capacity?! With what we're paying them for their administrative services?! And President Obama and Congress want to keep this industry in charge?!

This is not the time to sit back and see how the reform plays out. PPACA cannot ever insure everyone, and it cannot control the intolerable increases in spending. Now, more than ever, is the time for activism! Let's demand a health care program that we can believe in - an improved Medicare for all!