qotd: Is it true that 85% do not have to worry about premium increases?

ACASignups.net

September 6, 2016

Steve Davis & Robert Laszewski confirm what I've been saying all along: Appx. 40% of ACA indy market is OFF EXCHANGE.

By Charles Gaba

For 2 1/2 years, dating back to around February 2014, I've been trying to hammer home the importance of the OFF-exchange individual market. Time and time again I've been stunned at the seeming blind spot that people who should know better (such as Avik Roy) have regarding the millions of people who are enrolled in fully ACA-compliant policies, but are doing so directly through the carriers themselves. There are a few reasons why people buying individual/family policies would do this, but the most obvious one is simple: If you earn more than 400% of the Federal Poverty Level (around 97,000/year for a family of 4), there's no reason to jump through the extra hoops of enrolling through HealthCare.Gov or the other various ACA exchanges...because you don't qualify for federal financial assistance anyway. For whatever reason, however, numerous reporters, pundits and even the HHS Dept. itself keep acting as though this market doesn't exist.

How many people are we talking about here? Well, back in 2014 I estimated that roughly 8 million people had signed up as of mid-April...almost exactly the same as the 8.02 million who selected QHPs on the ACA exchanges, or about 50% of the total. That 8 million included several million transitional and grandfathered policy enrollees, however, though I wasn't sure what the breakout was.

By this year, the exchange-based number had grown to around 11.1 million as of March 2016, of course...but the off-exchange number has been tougher to estimate. I've generally estimated the total off-exchange indy market at around 8-9 million, with roughly 7-8 million of that consisting of people enrolling in ACA-compliant plans at full price, and another 1-2 million or so enrolled in ACA-noncompliant "grandfathered" or "transitional" policies.

This estimate has been strongly supported by Mark Farrah Associates, which pegs the total individual market in 2016 at around 20.5 million.

Well, today, Robert Laszewski stumbled upon an excellent piece of data diving by a reporter named Steve Davis, in which Davis dug up the broken-out enrollment numbers for a whole mess of Blue Cross carriers nationwide.

The overall picture is quite clear: Roughly 48% (2.3 million) of all individual policies sold by these carriers (Blue Cross only) are subsidized, while another 48% are ACA-compliant but unsubsidized (8% on exchange, 40% off exchange). The remaining 4% or so are grandfathered/transitional enrollees.

It's important to note that in the states where there's no Grandfathered/Transitional (GR/TR) numbers listed, some chunk of the "Off Exchange Unsubsidized" tally likely belongs in the GR/TR column. Even so, the above hard data is remarkably close to my own assumptions:

9.4 million on-exchange subsidized (47%)

1.7 million on-exchange unsubsidized (8%)

7.1 million off-exchange unsubsidized (ACA-compliant) (35%)

2.0 million off-exchange unsubsidized (NON-ACA compliant) (10%)

= 20.2 million total

http://acasignups.net/16/09/08/steve-davis-robert-laszewski-confirm-what-ive-been-saying-all-along-appx-40-aca-indy-market

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Comment by Don McCanne

More numbers. Moving directly to the point, HHS and others keep assuring us that the anticipated greater increase in ACA insurance premiums will not be a problem for the 85 percent of individuals who receive premium subsidies through the ACA exchanges. Well it is a problem not only for the 15 percent of individuals in the exchanges who do not receive subsidies but also for those who buy their individual plans outside of the exchanges.

Charles Gaba makes the point that the individual plans sold by the insurers both within and outside of the exchanges share a common risk pool.

So roughly 47 percent of plans sold by insurers servicing the exchanges are subsidized, but another 53 percent (10 percent of total are not ACA compliant) sold on and off the exchanges are not subsidized so the insured individual bears the full premium increase. So it is not 85 percent who do not have to worry, but rather it is closer to half of those with ACA compliant plans.

Middle-income individuals not only bear the brunt of the premium increases, but they also pay taxes that will be used to provide the subsidies for the higher premiums in the exchanges. This is one more example of why middle-income individuals have fared poorly under ACA.

Single payer would have been simpler, more equitable, and would have had better control of increases in health care spending that are contributing to higher premiums. We can still make the change.

qotd: Fewer are uninsured, but…

National Center for Health Statistics

September 2016

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January–March 2016

By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Emily P. Zammitti, M.P.H.

This report provides health insurance estimates from the first quarter of the 2016 National Health Interview Survey.

*  In the first 3 months of 2016, 27.3 million (8.6%) persons of all ages were uninsured at the time of interview — 1.3 million fewer persons than in 2015 and 21.3 million fewer persons than in 2010.

*  The percentage of persons under age 65 with private insurance enrolled in a high-deductible health plan (HDHP) increased, from 25.3% in 2010 and 36.7% in 2015 to 40.0% in the first 3 months of 2016.

*  In the first 3 months of 2016, among adults aged 18–64, 11.9% were uninsured at the time of interview, 19.5% had public coverage, and 70.2% had private health insurance coverage.

*  Among adults aged 18–64, the 12-month increase in the percentage with private coverage through the Health Insurance Marketplace or state-based exchanges — from 4.4% (8.6 million) in the first quarter of 2015 to 4.7% (9.2 million) in the first quarter of 2016 — was not statistically significant.

*  In the first 3 months of 2016, among adults aged 18–64, 24.7% of those who were poor, 23.6% of near poor, and 6.5% of not poor lacked health insurance coverage at the time of interview.

*  In the first 3 months of 2016, 24.5% of Hispanic, 13.0% of non-Hispanic black, 8.4% of non-Hispanic white, and 6.7% of non-Hispanic Asian adults aged 18–64 lacked health insurance coverage at the time of interview.

https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201609.pdf

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Comment by Don McCanne

Six years after the enactment of the Affordable Care Act, we have achieved less than half of the goal of covering all of the uninsured - a decline from 48.6 million in 2010 to 27.3 million earlier this year. Many are celebrating this as a great success, but others do not out of concern for the 27 million who remain uninsured. Besides, there are many other observations in this report that should concern advocates of health care justice for all.

Although 21.3 million uninsured gained coverage since 2010, the further reduction in the uninsured in the past year - 1.3 million - was not statistically significant. This suggests that we are close to the flat of the curve. The feasible patches to ACA are very unlikely to have much more than a negligible impact in further reducing the numbers of uninsured. We need a system that is designed to cover absolutely everyone, such as a single payer national health program.

For adults under 65, 70 percent are privately insured, predominantly through employer sponsored plans. Only 4.7% are insured through the exchanges. Those who dreamed that the nation would swarm to the exchanges because of their superior competitive markets of private plans (HHS even changed the name from exchange to marketplace) had better go back to their drawing boards, and think "improved Medicare for all".

Perhaps the most alarming trend is the increase in enrollment in high deductible health plans (HDHP). For those under age 65, the percentage has increased from 25.3% in 2010 to 40.0% earlier this year. This has been responsible for much of the financial hardship caused by medical bills for those who are insured. The system is not working well for them, and it is getting worse.

Some say that the answer to high deductible plans is to include health savings accounts (HSA), making them consumer-directed health plans (CDHP). But three-fifths of those with HDHPs do not even have an HSA, and for many of the other two-fifths, the HSAs are inadequately funded. Pretending that deductibles can be paid with empty or nonexistent savings accounts is not sound health policy.

Another concern is that the uninsured rates are higher amongst the poor, Hispanics, and non-Hispanic blacks. Although much still needs to be done to reduce inequities in health care, the task remains much more difficult without adopting an equitable health care financing system (single payer).

So when you see headlines this week stating that the number of uninsured is at an all time low, don't think, "a job well done." It wasn't.

qotd: Physicians spend two hours on EHRs and desk work for every hour of direct patient care

Annals of Internal Medicine

September 6, 2016

Allocation of Physician Time in Ambulatory Practice: A Time and Motion Study in 4 Specialties

By Christine Sinsky, MD; Lacey Colligan, MD; Ling Li, PhD; Mirela Prgomet, PhD; Sam Reynolds, MBA; Lindsey Goeders, MBA; Johanna Westbrook, PhD; Michael Tutty, PhD; and George Blike, MD

Background: Little is known about how physician time is allocated in ambulatory care.

Objective: To describe how physician time is spent in ambulatory practice.

Design: Quantitative direct observational time and motion study (during office hours) and self-reported diary (after hours).

Setting: U.S. ambulatory care in 4 specialties in 4 states (Illinois, New Hampshire, Virginia, and Washington).

Participants: 57 U.S. physicians in family medicine, internal medicine, cardiology, and orthopedics who were observed for 430 hours, 21 of whom also completed after-hours diaries.

Measurements: Proportions of time spent on 4 activities (direct clinical face time, electronic health record [EHR] and desk work, administrative tasks, and other tasks) and self-reported after-hours work.

Results: During the office day, physicians spent 27.0% of their total time on direct clinical face time with patients and 49.2% of their time on EHR and desk work. While in the examination room with patients, physicians spent 52.9% of the time on direct clinical face time and 37.0% on EHR and desk work. The 21 physicians who completed after-hours diaries reported 1 to 2 hours of after-hours work each night, devoted mostly to EHR tasks.

Limitations: Data were gathered in self-selected, high-performing practices and may not be generalizable to other settings. The descriptive study design did not support formal statistical comparisons by physician and practice characteristics.

Conclusion: For every hour physicians provide direct clinical face time to patients, nearly 2 additional hours is spent on EHR and desk work within the clinic day. Outside office hours, physicians spend another 1 to 2 hours of personal time each night doing additional computer and other clerical work.

Primary Funding Source: American Medical Association.

http://annals.org/article.aspx?articleid=2546704

For more on this study:

http://www.medpagetoday.com/PracticeManagement/PracticeManagement/60046

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Comment by Don McCanne

Although this study was somewhat selective and its generalizability may be limited, nevertheless, it does show that physicians spend a tremendous amount of time on work that does not involve direct clinical face time with patients. This study and other observations suggest that much of this work is related to record documentation.

What should be the purpose of the medical record? Its primary function should be to assist the health care professionals in caring for the patients. It reinforces memory of the clinical status to date, and it provides a source for newly consulted professionals to quickly assess the status of the patient.

What else does the record do? It provides documentation for those who determine what services should be billed for in fee-for-service models of payment (FFS). In capitation models, it provides evidence that contractual requirements were met. It provides data for various quality assessment programs, including P4P (pay for performance). It provides data for evaluation of payment models, including not only Medicare, Medicaid, CHIP, private insurance plans such as PPOs, EPOs, point of service, and health maintenance organizations, but also models such as patient centered medical homes, accountable care organizations, the Medicare shared savings program, merit-based incentive payment systems (MIPS), alternative payment models (APM), and endless others. The record serves as an information source for accreditation surveys. It also requires extra efforts to include information designed to provide defense in medical liability actions. Records also provide a rich research resource for the policy community as the wonks devise ever more ways of trying to convert the traditional patient service model of health care into a business model concerned more about flow of funds rather than optimal patient care. Those in the trenches can add innumerable other extraneous purposes of the medical record that burden them as they attempt to fulfill the requirements of the record, thereby reducing the face time needed for essential patient interactions.

Other studies have confirmed that much of this work is contributing to physician burnout, which has now reached epidemic proportions.

How about returning the record to the exclusive role of being a virtual clinical document that assists the health care team with care of the patient? That information alone would also be adequate to provide a basis for billing, whether FFS or capitation. So much of the other burdensome record keeping contributes to the extraordinary administrative excesses that characterize the U.S. health care system, wasting both money and time. Let's get back to what our health care system is all about - taking care of the patient.