Another school year has come to a close, it’s still daylight well into the evening these days here in the northern hemisphere, and I’ve got summer on the brain. So welcome to the Summertime! edition of the Health Wonk Review! Since King v. Burwell is on a lot of minds these days, I thought we’d kick things off with two posts that take radically different views on the case:
King v. Burwell – opposing viewpoints
Amy Lynn Smith at Healthinsurance.org has a must-read article that puts a human face on the lawsuit. Smith’s article introduces us to Leonard and Dawn Erina, a couple who are currently receiving $853/month in premium tax credits to make their health insurance affordable. Those subsidies will evaporate if the Supreme Court rules that subsidies aren’t permitted in the federally-facilitated marketplace; the King v. Burwell ruling is expected later this month. The Erina’s have no way to pay the full cost of their health insurance ($1,131 per month) without subsidies. But they take 19 medications between the two of them, and their lives literally hang in the balance right now. The Erinas are not an isolated example, and nearly six and a half million people (and possibly as many as eight million) will lose subsidies if the Court rules that subsidies can only be provided by state-run exchanges.
But not everybody agrees that a plaintiff win in King v. Burwell would be a bad thing. At InsureBlog, Hank Stern points out an upside: If the Court rules that subsidies aren’t allowed in the 34 states that use the federally-run exchange, coverage will likely become officially unaffordable for millions of people who are currently receiving subsidies. In that case, those people would be exempt from the individual mandate (which Stern sees as an upside in 
and of itself), and would be eligible to enroll in catastrophic coverage, which is currently only available to people under 30 or those who have an exemption from the individual mandate. Stern notes that some people would prefer catastrophic coverage (I don’t disagree with that – I’d buy a copper plan if they were available), and for them, a plaintiff win would be beneficial. But depending on how much subsidy they were receiving, they would likely still be paying more in premiums for the catastrophic plan than they were paying for a more comprehensive, subsidized plan.
Something’s fishy
Roy Poses, of Health Care Renewal, is – in my opinion – an expert at ferreting out fishy things in the healthcare industry. On many occasions, he’s pointed out the problems that can and do arise from conflicts of interest. So it’s no surprise that Poses is calling attention to a recent New England Journal of Medicine editorial that basically poo-pooed the idea that conflicts of interest are a problem in medicine. What is surprising is that the NEJM
published the editorial in the first place. Poses runs through a long list of logical fallacies in the NEJM editorial, and it’s hard to argue with his conclusion. Conflicts of interest don’t always result in problems. But they certainly can and do result in problems, and erring on the side of regulation and disclosure is clearly the right course of action. As Poses notes, the onus is on the parties involved in the conflict of interest to prove that it’s not causing a problem, as opposed to defaulting to the assumption that no problems are caused.
At Health Policy Analysis, Brad Wright explains Iowa’s recent push to move the state’s Medicaid population (including CHIP and enrollees who are newly eligible for Medicaid under Obamacare) onto managed care plans – despite the fact that only 22% of Iowa residents support the change. Wright notes that although Iowa’s governor is touting lower costs under a managed care program, privately managed Medicaid programs tend to be more expensive and do not have better health outcomes than traditional Medicaid. Wright explains that CMS has yet to grant a waiver for Iowa’s transition to a managed care Medicaid program, and he encourages readers to contact CMS to request that the waiver not be granted (contact information is in the post).
Healthcare costs and utilization
At Managed Care Matters, Joe Paduda explains that hospital list prices have increased by more than 10% in the last couple years. While privately-insured patients who go to in-network hospitals are largely insulated from the increases (unless their deductibles have gone up), people who seek out-of-network care typically have much higher deductibles – and many new plans with smaller networks don’t cover out-of-network care at all, meaning that patients would be on the hook for the higher hospital costs, in full, if they go outside the network. Paduda also explains that although Medicare has done an “admirable job holding down costs while increasing its focus on quality,” the higher hospital prices are impacting workers’ comp costs.
David Williams of Health Business Blog brings us “Hang up and dial 911” – a look at the reasons emergency services tend to be over-utilized, and a program in Reno, NV, that’s working to solve the problem. In short, people need fast access to healthcare for a variety of reasons, but not all of them are truly emergencies. In Reno, paramedics are being trained to assist some patients at their homes (or in an alternative location like a detox center), without the need to transport them to an emergency room. It certainly makes sense, and from the initial numbers, it looks like a great way to cut down in ED overcrowding while still providing high quality patient care.
John R. Graham at National Center for Policy Analysis has a very thought-provoking discussion about paying for mammograms. The US Preventive Services Task Force changed their guidelines a few years ago, recommending mammograms starting at age 50 instead of age 40. This caused an uproar for a time, and there’s still plenty of debate on the topic. Graham contends that if insurance weren’t involved in the transaction, the cost of mammograms would be lower, as would health insurance premiums. He asks whether it might make more sense to have women save money on premiums and decide whether or not to pay for their own mammograms. Good point, although there’s a significant body of research that indicates that people shy away from preventive services when they have to pay for them out-of-pocket – even if they have lower health insurance premiums. Certainly good food for thought.
Jason Shafrin, aka the Healthcare Economist, digs into patient compliance with antipsychotic medications. An estimated 40% of schizophrenic patients are non-adherent with their medications. Shafrin explains that medication side-effects play a significant role in this, as does cost (high drug copays, or lack of health insurance). In addition, patients who are substance abusers are less likely to remain on their medications, as are those who don’t believe that the medication is effective – a significant number of patients are happy to be non-compliant, as they avoid the side-effects of the medication.
Looking ahead – the future of healthcare
Susan Dentzer, senior policy advisor to the Robert Wood Johnson Foundation, has an article at Wing of Zock that addresses the Med School class of 2015. Dentzer’s focus is on the “triple aim” of medicine: the need for better health, better health care, and cost containment to make it affordable. Her address is excellent; she advises new physicians to “lose [themselves] in the service of others” and reminds them to steer clear of overtreatment and its potential financial ramifications for patients and our healthcare system as a whole. And in a heartfelt description of her own son’s medical treatment, she compels new physicians to have compassion for their patients. Definitely a must-read.
At the Population Health Blog, Jaan Sidorov explains how healthcare leaders must not only focus on today, they must also plan for the future. And although healthcare is particularly dynamic – and uncertain – right now, Sidorov draws on commentary from leaders in several diverse industries to show that there’s not one right answer when it come to strategy and planning. My takeaway? The key to success might be a flexible nature and a willingness to go with the flow – since none of us know exactly how the healthcare river is going to meander over the next couple decades.
At Health Affairs, Joe Selby, the Executive Director of the Patient-Centered Outcomes Research Institute (PCORI), explains PCORnet, a national health data resource, and how it’s “designed to allow the nation to conduct a range of comparative research studies more efficiently and less expensively.” PCORnet can aggregate data from a variety of different EHR structures, as each member “transform[s] their local source data, along with related information (e.g., the standard used locally), into a common data structure.” The system, which actively involves patients in the use of their data, is currently undergoing testing through demonstration studies, and should be ready for more research studies by the end of the year.
Julie Ferguson of Workers’ Comp Insider delves into insurance fraud, particularly in the workers’ comp arena. She notes that while employee fraud is relatively rare (especially when compared with doctor mills, premium fraud, and attorney fraud), it’s still frustrating and costly for employers when employees have fraudulent workers’ comp claims. Ferguson notes that tactics to track down fraudulent behaviors are too little too late – akin to closing the barn door after the horse has escaped. She presents some strategies that focus more on prevention and avoiding fraud in the first place – and they probably also result in happier workers who return to work more quickly after an injury.
That’s it for this edition of the Health Wonk Review. Happy reading, and enjoy your summer!