Monthly Archives: June 2017

The Doctor Is In. Co-Pay? $40,000

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For five-figure annual fees, boutique medical services offer the wealthiest Americans the chance to cut the line and receive the best treatment.

When John Battelle’s teenage son broke his leg at a suburban soccer game, naturally the first call his parents made was to 911. The second was to Dr. Jordan Shlain, the concierge doctor here who treats Mr. Battelle and his family.

“They’re taking him to a local hospital,” Mr. Battelle’s wife, Michelle, told Dr. Shlain as the boy rode in an ambulance to a nearby emergency room in Marin County. “No, they’re not,” Dr. Shlain instructed them. “You don’t want that leg set by an E.R. doc at a local medical center. You want it set by the head of orthopedics at a hospital in the city.”

Within minutes, the ambulance was on the Golden Gate Bridge, bound for California Pacific Medical Center, one of San Francisco’s top hospitals. Dr. Shlain was there to meet them when they arrived, and the boy was seen almost immediately by an orthopedist with decades of experience.

For Mr. Battelle, a veteran media entrepreneur, the experience convinced him that the annual fee he pays to have Dr. Shlain on call is worth it, despite his guilt over what he admits is very special treatment.

“I feel badly that I have the means to jump the line,” he said. “But when you have kids, you jump the line. You just do. If you have the money, would you not spend it for that?”

Increasingly, it is a question being asked in hospitals and doctor’s offices, especially in wealthier enclaves in places like Los Angeles, Seattle, San Francisco and New York. And just as a virtual velvet rope has risen between the wealthiest Americans and everyone else on airplanes, cruise ships and amusement parks, widening inequality is also transforming how health care is delivered.

San Francisco’s universal health care plan eyed as model for California

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San Francisco’s universal health care plan eyed as model for California

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Maria Consuelo believes she’s alive today because of a groundbreaking program this left-leaning city created a decade ago – one that guarantees health coverage to every one of its 864,000 residents.

It’s made San Francisco the only place in the country where truly universal health coverage exists, similar to what’s available in every other developed nation. Called Healthy San Francisco, it offers health care to those who can’t afford private insurance and are ineligible for other government health programs.

In Consuelo’s case, she visited a government-funded clinic in the fall of 2015 and told a doctor she had pain in her pelvis. Tests later showed cancer in her ovaries, leading to successful surgery to remove them in January 2016.

“This law really helped me,” Consuelo, a 55-year-old mother of five grown children, said while waiting to pick up some medication last week at San Francisco General Hospital. “If it could help others, that would be great.”

A similar thought is percolating in the mind of Lt. Gov. Gavin Newsom, a Democrat who helped implement the plan when he was San Francisco’s mayor.

Now, two years after he launched his campaign to succeed Gov. Jerry Brown, Newsom has been wondering: Would such a program work in every county in the Golden State?

His suggestion comes at a time when proposals for universal health care are receiving a surprising amount of attention. Last week, Sens. Ricardo Lara, D-Bell Gardens, and Toni Atkins, D-San Diego, unveiled details of their bill to create a single-payer system that would cover all California residents – just a few days after Vermont Sen. Bernie Sanders vowed to introduce a bill to launch a similar system nationwide.

Ironically, all of the universal health care buzz is coming after the GOP’s plan to replace the Affordable Care Act with a bare-bones substitute plan collapsed. The Congressional Budget Office had estimated that the Republican plan would have decreased the federal deficit by more than $300 billion, but increased the ranks of uninsured Americans by 24 million by 2026.

But Republicans in Congress are still vowing to chip away — if not replace — the law, commonly called “Obamacare,” which has insured five million Californians since 2014, bringing down the state’s uninsured rate from 17 percent to 7.1 percent in just three years.

Trump Budget, Revised AHCA, Credit Negatives for NFP Hospitals

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The one-two punch of massive cuts to Medicaid that are proposed in both the new budget and the House Republicans’ revised American Healthcare Act would result in cuts of close to $1 trillion over 10 years, analysis shows.

Cutting Medicaid by more than $860 million over the next decade would be a credit negative for states and not-for-profit hospitals, both of which would be left scrambling for alternative funding to cover the loss, according to a new report from Moody’s Investors Service.

Last week the Trump administration unveiled a budget proposal that includes $610 billion in cuts to core Medicaid services, and an additional $250 million in reductions to Medicaid expansion programs created under the Affordable Care Act.

The following day, the Congressional Budget Office released its scoring of the revised American Health Care Act – the Republican plan to repeal and replace the Patient Protection and Affordable Care Act and estimated that it would reduce Medicaid spending by $834 million through 2026.

“The proposals significantly change the longstanding Medicaid financing system and are credit negative for states and not-for-profit hospitals,” Moody’s said in an issues brief.

For states that don’t have the luxury of ignoring budget imbalances, the changes would increase pressure to either kick people off Medicaid, increase the state share of Medicaid funding, or cut payments to hospitals and other providers, Moody’s says.

Hospitals, particularly those serving a high mix of Medicaid patients, could expect to see reimbursement cuts and more cases of uncompensated care as Medicaid patients lose the coverage they’d gained under the ACA’s expansion.

Medicaid is already a significant budget burden for states, consuming between 7% to 34% of state revenue and averaging 16%.

Under the ACA, bad debt expense at not-for-profit hospitals in states that expanded Medicaid eligibility declined on average by 15% to 20% since 2014, enhancing these hospitals’ cash flow. Similarly, the gains in insurance coverage lowered the nationwide uninsured rate to approximately 11%, with uninsured rates even lower in states that expanded their Medicaid rolls, Moody’s says.

“Although the budget would give states limited new flexibility to adjust their Medicaid programs, the measure overall reflects a significant cost shift away from federal funding to states,” Moody’s says. “This cost shift is significant and would force states to make difficult decisions about safety-net spending for hospitals that serve large numbers of indigent patients.”

1 in 3 People in Medicare is Now in Medicare Advantage, With Enrollment Still Concentrated Among a Handful of Insurers

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Medicare Advantage 2017 Spotlight: Enrollment Market Update

Medicare Advantage plans have played an increasingly larger role in the Medicare program as the share of Medicare beneficiaries enrolled in Medicare Advantage has steadily climbed over the past decade.  The trend in enrollment growth is continuing in 2017, and has occurred despite reductions in payments to plans enacted by the Affordable Care Act of 2010 (ACA).  This Data Spotlight reviews national and state-level Medicare Advantage enrollment trends as of March 2017 and examines variations in enrollment by plan type and firm. It analyzes the most recent data on premiums, out-of-pocket limits, and quality ratings.  Key findings include:

  • Enrollment Growth. Since the ACA was passed in 2010, Medicare Advantage enrollment has grown 71 percent. As of 2017, one in three people with Medicare (33% or 19.0 million beneficiaries) is enrolled in a Medicare Advantage plan (Figure 1).

 

  • Market Concentration. UnitedHealthcare and Humana together account for 41 percent of enrollment in 2017; enrollment continues to be highly concentrated among a handful of firms, both nationally and in local markets. In 17 states, one company has more than half of all Medicare Advantage enrollment – an indicator that these markets may not be very competitive.

 

  • Medicare Advantage Penetration. At least 40 percent of Medicare beneficiaries are enrolled in Medicare private plans in six states: CA, FL, HI, MN, OR, and PA. In contrast, fewer than 20 percent of Medicare beneficiaries are enrolled in Medicare Advantage plans in 13 states, plus the District of Columbia.

 

  • Premiums and Cost-Sharing. While average Medicare Advantage premiums paid by MA-PD enrollees have been relatively stable for the past several years ($36 per month in 2017), enrollees may be liable for more of Medicare’s costs, with average out-of-pocket limits increasing 21 percent and average Part D drug deductibles increasing more than 9-fold since 2011; however, there was little change in out-of-pocket limits and Part D drug deductibles from 2016 to 2017.

Medicare Advantage enrollment is projected to continue to grow over the next decade, rising to 41 percent of all Medicare beneficiaries by 2027.1  As private plans take on an even larger presence in the Medicare program, it will be important to understand the implications for beneficiaries covered under Medicare Advantage plans and traditional Medicare, as well as for plans, health care providers and program spending.

Leadership Takes Self-Control. Here’s What We Know About It

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Philosophers and psychologists have been discussing the importance of self-control for ages. Plato, for example, argued that the human experience is a constant struggle between our desire and rationality, and that self-control is needed to achieve our ideal form. Likewise, Freud suggested that self-control is the essence of a civilized life.

The scientific study of self-control started about 25 years ago in the fields of criminology and psychology. Since then, hundreds of studies have shown the positive effects that come from possessing self-discipline. For instance, people with higher levels of self-control eat healthier, are less likely to engage in substance abuse, perform better at school, and build high-quality friendships. At work, leaders with higher levels of self-control display more effective leadership styles – they are more likely to inspire and intellectually challenge their followers, instead of being abusive or micromanaging. But what happens when people lack self-control at work?

We conducted a comprehensive review of research findings on employee self-control in a forthcoming paper in the Academy of Management Annals. Analyzing more than 120 management papers, we found that there are three main reasons why people occasionally lose self-control: 1) self-control is a finite cognitive resource; 2) different types of self-control tap the same pool of self-control resources; and 3) exerting self-control can negatively affect future self-control if it is not replenished. Think of self-control as analogous to physical strength: Our physical strength is limited, various tasks (e.g., football, basketball, walking, etc.) deplete it, and continued exertion can negatively affect future physical strength if it’s not restored.

For example, our own research has found that service employees in leadership positions who have to force a smile in customer interactions (thereby exercising self-control to suppress their true feelings) are later less able to regulate their interactions with their subordinates – they lie and are more rude to them.

Our review identified a few consequences that are consistently linked to having lower self-control at work:

  1. Increased unethical/deviant behavior: Studies have found that when self-control resources are low, nurses are more likely to be rude to patients, tax accountants are more likely to engage in fraud, and employees in general engage in various forms of unethical behavior, such as lying to their supervisors, stealing office supplies, and so on.
  1. Decreased prosocial behavior: Depleted self-control makes employees less likely to speak up if they see problems at work, less likely to help fellow employees, and less likely to engage in corporate volunteerism.
  1. Reduced job performance: Lower self-control can lead employees to spend less time on difficult tasks, exert less effort at work, be more distracted (e.g., surfing the internet in working time), and generally perform worse than they would had their self-control been normal.
  1. Negative leadership styles: Perhaps what’s most concerning is that leaders with lower self-control often exhibit counter-productive leadership styles. They are more likely to verbally abuse their followers (rather than using positive means to motivate them), more likely to build weak relationships with their followers, and they are less Scholars have estimated that the cost to corporations in the United States for such a negative and abusive behavior is at $23.8 billion annually.

Our review makes clear that helping employees maintain self-control is an important task if organizations want to be more effective and ethical. Fortunately, we identified three key factors that can help leaders foster self-control among employees and mitigate the negative effects of losing self-control.

First, sleep appears to have an amazing restorative effects on self-control. One study found that leaders who slept well at night (defined as having minimal interruptions to sleep) were much more likely to exercise their self-control and refrain from displaying abusive supervision, such as yelling and cursing at low-performing subordinates, compared to their counterparts who did not sleep well. Modern organizations often require employees to work beyond traditional office hours in the name of increased productivity. But this could be counter-productive and lead to negative workplace behaviors due to employees lacking self-control. Instead, organizations should be mindful about how long work hours can impact employees’ behavior and wellbeing. Google, for example, installed sleep pods at the office to allow employees to nap and be reenergized.

Second, “service with a smile” might not always pay. Service-oriented organizations often force employees to smile in front of customers. While this might please customers in the short-term, it can cause other organizational problems. Dropping this practice perhaps is not be a practical option, but companies should consider training employees to tap into the emotions they display. For example, another study showed that physicians who engaged in perspective taking and felt genuine empathy toward their patients did not experience reduced self-control and its associated negative workplace behaviors such as burnout, whereas physicians who were forced to fake empathic behaviors toward patients later reported increased burnout and lower job satisfaction. Service-oriented employees may also benefit from engaging in more perspective-taking rather than faking their emotions.

Third, creating the right environment may help prevent some of the negative behaviors associated with lower self-control. For example, we came across research showing that employees with low self-control were no more likely to engage in deviant behavior when organizations promoted an ethical culture —displaying the company’s code of conduct where employees could see it made them less tempted to behave unethically. This type of intervention tends to be very effective in the short-term.

Ultimately, the keys to avoiding self-control failures are to 1) allow the body to rest and restore self-control, 2) reexamine existing organizational policies that might inadvertently reduce employees’ self-control, and 3) create a culture that deters negative behaviors in moments of reduced self-control.