qotd: Health navigators for everyone

Kaiser Health News
August 13, 2014
More Employers Limit Health Plan Networks But Seek To Preserve Quality,
Says Adviser
By Mary Agnes Carey

Dr. Robert Galvin is chief executive officer of Equity Healthcare (a
wholly owned subsidiary of Blackstone, a global investment and advisory
firm), where he works with executives of nearly 50 companies that
purchase health coverage for 300,000 people. Galvin says the 2010
Affordable Care Act has made employers more engaged in health benefits
while encouraging their workers to be savvier health care consumers.

"I think what the ACA has done more than anything is it has made every
employer examine their strategy and in every case it's bringing the CFO
and the CEO" into decisions about the company's health care, which often
didn't use to happen, he said.

Q: We're hearing a lot these days about narrow networks. While they
existed before the ACA, how are employers using tools like narrow
networks or high-deductible plans to control costs?

A: Those employers who are going to stay in the game – which is the
majority of them – in many cases have to [improve] what they're
covering. They now have to use the managed care tools that they all
abandoned 15 years ago.

So the answer is narrow networks – we now call them "performance
networks" – they are definitely increasing in popularity. And I think
what we're trying to do differently this time is to make them
performance [based] and not just narrow.

The second change from the '90s is always offering options outside of
the narrow network. So rather than "Here's your narrow network, that's
it," it's, "Here's your performance network that is going to be less
expensive for you. If you want to, [you have the option] of paying
considerably more money, and getting to another network, or another
physician."

I think what we learned in the '90s was that Americans want choice, even
if it's the wrong choice.

On the high deductible side, there's absolutely a move in that
direction. The way we think about it, we're trying to make more
informed consumers.

This is a more intelligent way of getting people more involved in their
health decisions. I think the thing to watch, honestly, is the full
replacement high deductible. [There's] no [preferred provider option],
no point-of-service. All you have is a high deductible. There's still
in and out of network but what it means as an employee is you can't
choose between a PPO where you pay $20 to see your doctor or a high
deductible where you'll have to pay $120. The only option you have is
the high deductible. About 20 percent of the commercial companies have
that. The key thing to watch is how many companies basically only offer
high deductibles. It's about 20 percent now but I think that's going to
grow double-digits every year.

Q: Does the ACA need the employer mandate to work?

A: My bottom line feeling about that is no.

I think people in government have absolutely no idea what kind of work
and complexity [employers face] for what seems like a simple regulation.
In terms of who's eligible, who's tracking hours, doing the look back,
what you have for HR systems to manage the reporting requirements,
actually administering that is a nightmare.

Q: How do employers help their employees understand more about the
health care they're purchasing?

A: The first thing is they need to make employees price sensitive.
Time has shown that all the education you can give someone really only
impacts a small percent of employees who are interested anyway.

With more price sensitivity is an obligation, if you want the market to
work, for information. And information that works for individuals. More
companies are giving [employees] access to health navigators, or health
coaches. So that if you look at information on the computer or you
don't have broadband or you don't know what it means, you have someone
to call who can walk you through it.

It's a real need in the market to be able to call a navigator or a
coach, not through an insurance company, but a free-standing company and
have that person help employees figure things out.

Along with price sensitivity has to come the support.

http://www.kaiserhealthnews.org/Stories/2014/August/13/More-Employers-Limit-Health-Plan-Networks-But-Seek-To-Preserve-Quality.aspx

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Equity Healthcare (a subsidiary of Blackstone)

Equity Healthcare works with private equity firms and their portfolio
companies to bring innovative solutions to manage health care costs.

http://www.equityhealthcare.com/default.aspx

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Blackstone

At Blackstone, we apply our strengths as a leading global investment and
advisory firm to deliver solutions, unlock value and propel growth.

Above all, we have made it our No. 1 priority to serve the needs of our
investors and clients.

http://www.blackstone.com/the-firm/overview/why-blackstone

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Comment by Don McCanne

Follow the logic. To receive greater value in health care, we need to
put the patients in charge of purchasing decisions by exposing them to
price sensitivity - requiring out-of-pocket payment of high deductibles.
We also have to use the managed care tools of 15 years ago - provider
networks - but which are now narrower, so we are renaming them
"performance networks." But this does increase the complexity of a
system already infamous for its administrative excesses. So what can we
do to improve the patient's ability to negotiate this complex maze of
market-oriented health care?

Simple. Let's provide each patient with a "health navigator" or "health
coach." They can help patients figure out how this thing works. Of
course, they can't give medical advice, but they can provide additional
administrative services to assist the patient. Equity Healthcare
promotes free-standing companies that provide health navigator services
- more administrative services, but no health care services, but at
least these entities can help fulfill the mission of serving the needs
of Blackstone's investors.

We gain more administrative services and greater investor opportunity at
a cost of reducing patient choices in health care while exposing them to
potential financial hardship. Is that how markets are supposed to work?
Making things worse for patients while imposing on them the costs of yet
more superfluous administrative services? Adam Smith would be perplexed.
Producers gain by serving consumers, yet today producers are abusing
consumers to achieve their gains. Isn't it time to replace the invisible
hand of the market with the opaque hand of government by establishing
our own single payer national health program?

qotd: Both Medicaid and uninsured patients face disparities in care of deadly cancers

Journal of Clinical Oncology
August 4, 2014
Disparities in Stage at Diagnosis, Treatment, and Survival in Nonelderly
Adult Patients With Cancer According to Insurance Status
By Gary V. Walker, Stephen R. Grant, B. Ashleigh Guadagnolo, Karen E.
Hoffman, Benjamin D. Smith, Matthew Koshy, Pamela K. Allen and Usama Mahmood

Abstract

Purpose
The purpose of this study was to determine the association of insurance
status with disease stage at presentation, treatment, and survival among
the top 10 most deadly cancers using the SEER database.

Patients and Methods
A total of 473,722 patients age 18 to 64 years who were diagnosed with
one of the 10 most deadly cancers in the SEER database from 2007 to 2010
were analyzed. A Cox proportional hazards model was used for
multivariable analyses to assess the effect of patient and tumor
characteristics on cause-specific death.

Results
Overall, patients with non-Medicaid insurance were less likely to
present with distant disease (16.9%) than those with Medicaid coverage
(29.1%) or without insurance coverage (34.7%; P < .001). Patients with
non-Medicaid insurance were more likely to receive cancer-directed
surgery and/or radiation therapy (79.6%) compared with those with
Medicaid coverage (67.9%) or without insurance coverage (62.1%; P <
.001). In a Cox regression that adjusted for age, race, sex, marital
status, residence, percent of county below federal poverty level, site,
stage, and receipt of cancer-directed surgery and/or radiation therapy,
patients were more likely to die as a result of their disease if they
had Medicaid coverage (hazard ratio [HR], 1.44; 95% CI, 1.41 to 1.47; P
< .001) or no insurance (HR, 1.47; 95% CI, 1.42 to 1.51; P < .001)
compared with non-Medicaid insurance.

Conclusion
Among patients with the 10 most deadly cancers, those with Medicaid
coverage or without insurance were more likely to present with advanced
disease, were less likely to receive cancer-directed surgery and/or
radiation therapy, and experienced worse survival.

http://jco.ascopubs.org/content/early/2014/08/01/JCO.2014.55.6258.abstract

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Comment by Don McCanne

Clearly, insured patients with one of the most deadly cancers have
better outcomes than uninsured patients. Of concern is that this study
shows that patents on Medicaid do not do much better than uninsured
patients. What can we make of this?

Medicaid coverage is limited to low-income populations. These people
have many other problems that can result in impaired access and impaired
outcomes - conceivably enough to explain these differences. However,
Medicaid also may result in impaired access because of a lack of an
adequate number of physicians who are willing to care for Medicaid
patients. This is particularly true of specialists, such as oncologists
who would otherwise care for these patients with the most deadly
cancers. Impaired access due to a lack of willing providers applies to
both uninsured and Medicaid patients. That is not true for either
privately insured or Medicare patients.

Under a well designed single payer system - an improved Medicare for all
- physicians would not cull patients out of their practices merely
because they were on Medicaid or uninsured. Enacting single payer would
allow us to remove barriers based simply on the type of insurance
coverage or lack thereof. That would then allow us address other
important societal issues that result in impaired access, delayed or
forgone management, and impaired survival.

Although this study will be used by opponents as an excuse not to fund
Medicaid based on the fact that Medicaid patients did not do much better
than the uninsured, we cannot allow them to discount the other factors
faced by low-income patients that undoubtedly played a greater role in
these disparate outcomes. Many other studies have shown that Medicaid
patients definitely fare better than the uninsured. Until we can enact
and implement a single payer system, it is imperative that Medicaid
continue to be offered as an interim measure.

qotd: Most uninsured will be exempt from penalties

The Wall Street Journal
August 6, 2014
Fewer Uninsured Face Fines as Health Law's Exemptions Swell
By Stephanie Armour

Almost 90% of the nation's 30 million uninsured won't pay a penalty
under the Affordable Care Act in 2016 because of a growing batch of
exemptions to the health-coverage requirement.

The architects of the health law wanted most Americans to carry
insurance or pay a penalty. But an analysis by the Congressional Budget
Office and the Joint Committee on Taxation said most of the uninsured
will qualify for one or more exemptions.

The Obama administration has provided 14 ways people can avoid the fine
based on hardships, including suffering domestic violence, experiencing
substantial property damage from a fire or flood, and having a canceled
insurance plan. Those come on top of exemptions carved out under the
2010 law for groups including illegal immigrants, members of Native
American tribes and certain religious sects.

Factoring in the new exemptions, the congressional report in June
lowered the number of people it expects to pay the fine in 2016 to four
million, from its previous projection of six million.

http://online.wsj.com/articles/fewer-uninsured-face-fines-as-health-laws-exemptions-swell-1407378602

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Congressional Budget Office
June 5, 2014
Payments of Penalties for Being Uninsured Under the Affordable Care Act:
2014 Update

Under the Affordable Care Act, most legal residents of the United States
are required to obtain health insurance or pay a penalty.

CBO and JCT have estimated that about 30 million nonelderly residents
will be uninsured in 2016 but that the majority of them will be exempt
from the penalty. Those who are exempt include:

* Unauthorized immigrants, who are prohibited from receiving almost all
Medicaid benefits and all subsidies through the insurance exchanges;
* People with income low enough that they are not required to file an
income tax return;
* People who have income below 138 percent of the federal poverty
guidelines (commonly referred to as the federal poverty level) and are
ineligible for Medicaid because the state in which they reside has not
expanded eligibility by 2016 under the option provided in the ACA;
* People whose premium exceeds a specified share of their income (8
percent in 2014 and indexed over time); and
* People who are incarcerated or are members of Indian tribes.

CBO and JCT estimate that 23 million uninsured people in 2016 will
qualify for one or more of those exemptions. Of the remaining 7 million
uninsured people, CBO and JCT estimate that some will be granted
exemptions from the penalty because of hardship or for other reasons.

All told, CBO and JCT estimate that about 4 million people will pay a
penalty because they are uninsured in 2016 (a figure that includes
uninsured dependents who have the penalty paid on their behalf).

http://www.cbo.gov/publication/45397

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Comment by Don McCanne

The Affordable Care Act was designed with incentives for almost everyone
to obtain insurance. A financial penalty was to be assessed against any
individual who remained uninsured, but now almost 90 percent of the
uninsured will be exempt from the penalty. Larger employers were to be
penalized if their employees remained uninsured, but now there is
bipartisan support to eliminate the employer mandate. The expansion of
Medicaid was to occur in all states but it has now been declined by
about half of the states. Even with legislative patches, this fragmented
system can never ensure that everyone has adequate health care coverage.

Compare this to a single pager system in which absolutely everyone would
have been automatically enrolled in a better plan than any of those
currently available, including Medicare. Why is there no clamoring for
change?