Fwd: qotd: Patients object to physicians' focusing on costs

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-------- Original Message --------
Subject: qotd: Patients object to physicians' focusing on costs
Date: Tue, 5 Feb 2013 08:37:33 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Health Affairs
February 2013
Focus Groups Highlight That Many Patients Object To Clinicians' Focusing
On Costs
Roseanna Sommers, Susan Dorr Goold, Elizabeth A. McGlynn, Steven D.
Pearson and Marion Danis

Abstract

Having patients weigh costs when making medical decisions has been
proposed as a way to rein in health care spending. We convened
twenty-two focus groups of people with insurance to examine their
willingness to discuss health care costs with clinicians and consider
costs when deciding among nearly comparable clinical options. We
identified the following four barriers to patients' taking cost into
account: a preference for what they perceive as the best care,
regardless of expense; inexperience with making trade-offs between
health and money; a lack of interest in costs borne by insurers and
society as a whole; and noncooperative behavior characteristic of a
"commons dilemma," in which people act in their own self-interest
although they recognize that by doing so, they are depleting limited
resources. Surmounting these barriers will require new research in
patient education, comprehensive efforts to shift public attitudes about
health care costs, and training to prepare clinicians to discuss costs
with their patients.

From a discussion of Implications

The focus-group discussions revealed the following barriers to
participants' choosing less expensive care: the salience of unlikely but
highly upsetting possibilities; a desire for zero risk, rather than for
reasonable risk reduction; an assumption that price always signals
quality; the misperception that health care sustainability can be
achieved by eliminating wasteful spending alone, without needing to
forgo some marginally beneficial care; and the belief that choosing more
expensive care constitutes a kind of victory for patients over the
insurance companies.

Conclusion

If patients and clinicians do not discuss and consider costs during the
clinical encounter, the alternatives are problematic. Clinicians might
make cost-conscious decisions—for example, judging when high-priced
resources such as operating room times, hospital beds, imaging, and
specialty referrals are warranted—without informing patients that cost
considerations influenced their decisions. Evidence from other countries
indicates that clinicians do occasionally limit the use of medical
interventions on the basis of concerns about cost. Yet another
alternative would be to make cost-conscious allocation decisions at the
organizational level, with minimal clinician involvement.

Given the long-term projections about health care costs in the United
States, it is inevitable that physicians will face increasing pressures
to deliver cost-effective care to their patients. Doing so openly, in a
way that allows patients an opportunity to hear the justification for
cost-conscious decisions and to be active agents in thinking through
treatment choices when feasible, is consistent with physicians' ethical
duties to be transparent with patients and to provide patient-centered care.

But this study's findings suggest that for cost to be an explicitly
recognized and discussed factor in clinical decisions, public attitudes
about health care costs must first undergo a significant shift.

http://content.healthaffairs.org/content/32/2/338.abstract


Comment: Much attention is being directed today toward the very high
costs that plague the U.S. health care system. That attention has not
equated with effectiveness in controlling costs, as we witness continued
increases in spending in spite of introduction of policies that may be
well-meaning but not very effective, that may add to the administrative
excesses of our system, and that sometimes are detrimental such as when
we erect financial barriers to beneficial health care services.

Some of the emphasis has been directed toward increasing the engagement
of the "medical consumer" in the decision process, often through the
policies of consumer-directed health care. These policies are designed
to make patients "better health care shoppers" by forcing them to
recognize costs as they spend some of their own money on health care.
The most common measure is to increase the deductibles and other forms
of cost sharing that the patient must face when accessing care.

This important study used focus groups to determine the attitudes of
potential patients toward injecting cost considerations into the
delivery of health care. Patients don't like it. They feel that they
should receive the care that they should have without insurers or public
programs making decisions on covering care based on cost considerations.
Even if it is their own money, they do not want to compromise their care
based on cost.

Other high-quality systems that are much less expensive than ours are
able to provide care with first dollar coverage, eliminating the
requirement that the patient be involved or even concerned about the
costs of the care that they receive. We do not need to create an
environment of distrust by the patient that would be engendered by
thoughts of health care services being withheld for reasons of cost.

We can make far better clinical decisions based on studies generating
guidelines such as those by the British National Institute for Health
and Clinical Guidance (NICE). An example of how this works is in their
guidance for "Cetuximab, bevacizumab and panitumumab for the treatment
of metastatic colorectal cancer after first-line chemotherapy,"
available at this link:
http://guidance.nice.org.uk/TA242/Guidance/pdf/

If we replaced our fragmented, dysfunctional financing system with an
efficient single payer system, and then applied rational decision making
processes for diagnostic and therapeutic interventions, we would not
have to have the patient involved in spending decisions. Those decisions
could be made on a macro-system basis by better planning of system
capacity and distribution, and then incorporating a greater element of
evidence-based decision making.

We really don't need angry, me-first patients provoked by having cost
decisions forced upon them, particularly when the cost transparency
demanded by the advocates of consumer-directed health care creates
hostility towards health care professionals and third party payers whom
they believe are withholding care that they should have, whether it is
true or not.

Fwd: qotd: CMS shows that the healthy go in and the sick come out of Medicare Advantage plans

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-------- Original Message --------
Subject: qotd: CMS shows that the healthy go in and the sick come out
of Medicare Advantage plans
Date: Mon, 4 Feb 2013 08:53:45 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



Centers for Medicare & Medicaid Services
Medicare & Medicaid Research Review
2012: Volume 2, Number 4
Impact of Continued Biased Disenrollment from the Medicare Advantage
Program to Fee-for-Service
By Gerald F. Riley

Background: Medicare managed care enrollees who disenroll to
fee-for-service (FFS) historically have worse health and higher costs
than continuing enrollees and beneficiaries remaining in FFS.
Objective: To examine disenrollment patterns by analyzing Medicare
payments following disenrollment from Medicare Advantage (MA) to FFS in
2007. Recent growth in the MA program, introduction of limits on timing
of enrollment/disenrollment, and initiation of prescription drug
benefits may have substantially changed the dynamics of disenrollment.

Conclusions: Despite substantial changes in policies and market
characteristics of the Medicare managed care program, disenrollment to
FFS continues to occur disproportionately among high-cost beneficiaries,
raising concerns about care experiences among sicker enrollees and
increased costs to Medicare.

Discussion

Despite substantial changes in policies and market characteristics of
the Medicare managed care program, disenrollment to FFS continues to
occur disproportionately among high-cost beneficiaries. Disenrollees had
higher risk scores and incurred higher risk-adjusted payments than
beneficiaries in FFS. Their high risk scores are in contrast to the risk
scores of the general MA population, most of which is enrolled in plans
with average risk scores similar to or less than local FFS experience
(United States Government Accountability Office, 2010). Recent studies
have also shown that MA plans continue to experience favorable selection
through enrollment of low-cost beneficiaries (MedPAC, 2012; Riley,
2012). These research findings suggest a pattern of selective
disenrollment whereby disenrollees are sicker and more expensive than
the beneficiaries who remain enrolled in MA plans. This selective
disenrollment potentially increases Medicare costs through the return of
high-cost beneficiaries to the FFS sector, leaving behind a healthier
and lower-cost population in the capitated MA sector.

The Affordable Care Act mandated changes to MA payment methods that will
result in significant decreases in payment rates and bring them closer
in line with plan costs. This may intensify pressure on plans to
encourage selective disenrollment.

Disenrollees from PPOs and PFFS plans incurred lower payments
post-disenrollment than disenrollees from HMOs and similar types of
plans, and their average payments were closer to predicted levels.
Possible explanations include a less chronically ill disenrollee
population from PPO and PFFS plans, or less unmet demand for services
when they transitioned to FFS. Less selective disenrollment from PPO and
PFFS plans may be attributable to the more extensive network of
providers available under these types of plans. Beneficiaries with
chronic illnesses have a greater choice of physicians to manage their
conditions and have more opportunities to switch providers if they
become dissatisfied with their care. This expanded choice of providers
may reduce the incentives for chronically ill enrollees to leave these
types of plans.

http://www.cms.gov/Research-Statistics-Data-and-Systems/Research/MMRR/Downloads/MMRR2012_002_04_A08.pdf


Comment: Earlier studies of the Medicare + Choice plans and more recent
studies of the successor Medicare Advantage plans have shown that, when
it comes to managed care, the healthy go in and the sick come out.
Taxpayers are paying more for the healthier, less-costly patients who
are enrolled in the Medicare Advantage plans, and then pay more for the
sicker patients who return to the traditional Medicare program (adverse
selection). This CMS study adds to that evidence.

One interesting finding in this study is that those enrolled in PPO or
FFS Medicare Advantage plans did not show as great post-enrollment cost
increases. It is likely that the patients did not experience as much of
a limitation in services in PPO plans, such as those offered by Blue
Cross and Blue Shield, since their networks tend to include a much
larger percentage of the physician population.

There are two important take-home points here. One is that we should
stop wasting taxpayer funds on both the excesses of the Medicare
Advantage plans, and the costly adverse selection burden that they place
on the traditional Medicare program.

The other point is that we should reject the policies of the private
insurance sector that is taking away our health care choices by
establishing networks of health care providers. Our traditional Medicare
program includes a choice of any provider, except for the rare physician
who totally opts out of the Medicare program.

For greater economy and expanded choice, we should change to a program
of an improved Medicare for everyone.

Fwd: qotd: AHIP's report on physician out-of-network charges

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-------- Original Message --------
Subject: qotd: AHIP's report on physician out-of-network charges
Date: Fri, 1 Feb 2013 14:14:27 -0800
From: Don McCanne <don@mccanne.org>
To: Quote-of-the-Day <quote-of-the-day@mccanne.org>



AHIP (America's Health Insurance Plans)
February 1, 2013
New Report Examines Physician Out-of-Network Charges

A new report from America's Health Insurance Plans (AHIP) highlighting
data collected by Dyckman & Associates shows that some physicians who
choose not to participate in health insurance networks are charging
patients fees that are 10 times – and in some cases, nearly 100 times –
Medicare reimbursement for the same service in the same geographic area.
Looking at the 30 largest states, the report found that some physicians
who do not take insurance are charging patients startling fees for a
wide variety of medical treatments and services.

This report demonstrates the importance of public policy leaders
focusing on how much patients who seek out-of-network care are being
charged by some physicians. In discussions to date, the focus only has
been on how much insurers pay for these services, and the critical issue
of what out-of-network physicians charge patients has been ignored.

The findings of the report should cause policymakers to closely
investigate this issue, especially considering how these charges compare
to in-network fees, as well as fees charged for similar services in
other countries. For example, in New York, a physician billed a patient
$115,625 for lumbar spinal fusion – 62 times the Medicare fee of $1,867.

While the issue of how much is appropriate for out-of-network physicians
to charge has not been part of the affordability discussion to date,
this report demonstrates that it needs to be. No mechanism exists to
protect patients who seek care out-of-network from receiving bills that
are unreasonable and unaffordable.

"As we shine a spotlight on the affordability issue, we encourage
policymakers to look at how much is being charged for services,
particularly since there is often no relationship between higher charges
and higher quality of care," said AHIP President and CEO Karen Ignagni.
"With the nation facing the crushing burden of rising medical costs, all
stakeholders should be focusing on constructive ways to bring costs
under control."

https://www.ahip.org/News/Press-Room/2013/New-Report-Examines-Physician-Out-of-Network-Charges.aspx

AHIP infographic on highest out-of-network charges:
http://www.ahipcoverage.com/wp-content/uploads/2013/01/OutOfNetwork_National_V17_FV.jpg


Comment: The insurance lobby organization, AHIP, is correct when they
point out that patients are not protected from exorbitant fees charged
by physicians outside of their own insurance networks. Although this
report appropriately condemns outrageous fee gouging, the report itself
is deceptive, reflecting on AHIP's own credibility.

AHIP asked its insurers to provide the three highest billed charges from
non-participating providers for each of 24 CPT procedure codes. They
then took the very highest charge for 10 procedures and created a graph
demonstrating how outrageous these charges were compared to Medicare
rates. They distributed the graph with their press release.

Although the bar graph is quite impressive (link above), it represents
only ten specific instances of fee gouging. Yet the infographic -
labeled "Out-of-Network Charges" - is presented as if it were
representative of charges made by out-of-network providers (though it
does state that these are the highest reported out-of-network provider
charges).

Nowhere in the 26 page report is there any mention of what fees were
actually paid. Although the insurer pays no more than its allowed
out-of-network charges, if any, does the patient pay the rest? No. Often
the patients are able to negotiate payments that are closer to typical
commercial insurance rates. Sometimes the patient simply doesn't pay at
all, though the claim may be turned over to a collection agency.
Regardless, the AHIP report is deceptive since it represents only a few
outrageous billing charges but does not represent actual typical
out-of-network payments.

In this press release, AHIP implies that there needs to be a mechanism
"to protect patients who seek care out-of-network from receiving bills
that are unreasonable and unaffordable." In essence, they are saying
that the government should require out-of-network providers to accept
rates similar to those agreed to through contracts with the in-network
providers.

Think about that. The only mechanism that insurers have introduced to
slow the increase in heath care spending has been provider contracting.
Okay. Let's accept their implicit recommendation. Let's do what other
industrialized nations do and use some form of government administered
pricing. Then there would be no reason for the insurers to establish
exclusive provider networks.

Since the insurers then would have nothing substantial to offer other
than claims processing, we can do away with much of their administrative
and marketing waste. In fact, we can do away with them completely by
establishing our own universal health insurance administrator - a single
payer national health program.

As AHIP CEO Karen Ignagni says, "With the nation facing the crushing
burden of rising medical costs, all stakeholders should be focusing on
constructive ways to bring costs under control." She's right. The first
step should be to get rid of the private insurers.