http://www.healthaffairs.org/podcasts/terminating-cost-sharing-reduction-payments
In a WTOP-FM interview, Alan Weil assesses the CBO’s report on the impact on premiums and the deficit if CSR payments were eliminated.
Tag Archives: ACA
Public Health Care Programs: Lower Cost but Not Lower Quality
Public Health Care Programs: Lower Cost but Not Lower Quality
In recent days, Democrats have stepped into the health policy vacuum created by the Republicans’ failure to repeal and replace the Affordable Care Act. Proposals making the rounds include allowing Americans to buy into Medicare at age 55 or to buy into Medicaid.
Both Medicare and Medicaid pay lower prices to health care providers compared with private market plans offered by employers and in the Affordable Care Act marketplaces. On that basis, you might think these public programs are more cost-efficient. Are they?
Imagine that I take my car to the cheapest mechanic in town, while you take yours to the most expensive. My repairs, though costing less, don’t always fix the problem or last as long. You get what you pay for.
Let’s take a look at whether something similar is happening with public health programs. One study examined claims data for 26 low-value services and found that as much as 2.7 percent of Medicare’s spending is on these services alone, which include ineffective cancer screening, diagnostic testing, imaging and surgery. That sounds pretty bad.
But a paper that appeared in Health Services Research this year suggests that private plans do not perform better. Looking at the years 2009 to 2011, the authors compared the rates at which Medicare and private health plans provided seven low-value services. The services compared were among those identified as unnecessary by national organizations of medical specialists as part of the Choosing Wisely campaign.
The researchers found that four of the seven services they examined were provided at similar rates by Medicare and commercial market plans: cervical cancer screening over age 65; prescription opioid use for migraines; cardiac testing in asymptomatic patients; and frequent bone density scans. Medicare was less likely to pay for unnecessary imaging for back pain, but more likely to pay for vitamin D screening.
This finding might seem counterintuitive. Commercial market plans pay higher rates and confer higher profit margins, meaning there is more financial incentive for physicians to provide privately insured patients more of all types of care, whether low or high value.
But other results from the study suggest a more likely explanation: Doctors tend to treat all their patients similarly, regardless of who is paying the bill.
“What kind of insurance you have does affect your access to health care,” said Carrie Colla, associate professor of the Dartmouth Institute for Health Policy & Clinical Practice and the lead author of the study. “But once you’re in front of the doctor, by and large you’re treated the same way as any other patient.”
One apparent exception found in the study involved the seventh service it examined: cardiac testing before low-risk, noncardiac surgery. This service was provided to 46 percent of Medicare beneficiaries and 26 percent of privately insured patients. The large difference could reflect the fact that cardiac problems are more prevalent among older people. So a doctor with equal concern for all her patients might test Medicare patients at a higher rate for that reason. Nonetheless, such testing is considered low value even for the Medicare population.
Another recent study, published in JAMA Internal Medicine, also found little relationship between insurance status and low-value care. The study found no difference in the rates at which seven of nine low-value services were provided to patients on Medicaid versus those with private coverage. Six were also provided at the same rates for uninsured and privately insured patients.
Moreover, the study found that physicians who see a higher proportion of patients on Medicaid provide the same rate of low- and high-value services for all their patients as other physicians do. This is an important finding because Medicaid pays doctors less than private plans do, raising concerns that higher-quality doctors would tend not to participate in the program.
“Despite concerns to the contrary, Medicaid patients don’t appear to be seeing lower-quality doctors,” said Dr. Michael Barnett, lead author of the study, a physician with the Brigham and Women’s Hospital and an assistant professor at the Harvard T.H. Chan School of Public Health. “Though raising the prices Medicaid pays doctors may increase physician participation, enhancing enrollees’ access to care, it isn’t likely to change the quality of care patients receive once they are in the doctor’s office.”
If insurance status doesn’t influence how much low-value care patients are being offered, what does? In part, it seems related to the history and organization of local health care markets. A big culprit, according to Ms. Colla’s study, is a market’s ratio of specialists, like cardiologists and orthopedists, to primary care physicians. In areas where there are relatively more specialists, there is also more low-value care. That’s not to say that specialists don’t provide valuable services — but it suggests that they tend to provide more low-value care as well.
In a way, this is good news — the medical system doesn’t seem to discriminate by insurance status. It also means that public programs appear to be relatively cost-efficient, spending less than private payers for care of similar quality. That bodes well for Democrats’ proposals to expand Medicare or Medicaid.
But the bad news is that the study results imply that the value of care is hard to influence by adjusting prices. In a normal market, paying less for something would send a message of its low value, prompting people to provide less of it. The fact that price apparently does not influence doctors’ decisions is just another way in which health care does not seem to function like other markets.
5 Outside-The-Box Ideas For Fixing The Individual Insurance Market
With Republican efforts to “repeal and replace” the Affordable Care Act stalled, tentative bipartisan initiatives are in the works to shore up the fragile individual insurance market that serves roughly 17 million Americans.
The Senate Health, Education, Labor and Pensions Committee launches hearings the week Congress returns in September on “stabilizing premiums in the individual insurance market” that will feature state governors and insurance commissioners. A bipartisan group in the House is also working to come up with compromise proposals.
Both before and after implementation of the federal health law, this market — serving people who don’t get coverage through work or the government — has proved problematic. Before the law, many people with preexisting health conditions could not get insurance at any price. Now, consumers in the individual market often face higher out-of-pocket costs and fewer choices of health care providers and insurers than in past years. More than 12 million people buy that insurance through the ACA’s marketplaces, while another 5 million buy it outside of the exchanges.
Policymakers generally agree on what immediate efforts to stabilize the market might include. At the top of most lists is ensuring federal payment of subsidies to insurers to pay the out-of-pocket expenses — such as deductibles and copayments — to protect customers with the lowest incomes. Insurers also want the federal government to continue enforcing the requirement that most Americans either have insurance or pay a tax penalty, and continuing efforts to get uninsured people to sign up for coverage during the upcoming open enrollment period, from Nov. 1 to Dec. 15. Those efforts are essential, insurers say, to help keep healthy customers in their risk pools to defray the costs of beneficiaries with medical needs.
But what about ideas that go beyond the oft-repeated ones? Here are five proposals that are more controversial but generating buzz.
State officials take center stage in ACA stabilization efforts
As efforts to stabilize the Affordable Care Act exchanges begin to take shape, it’s become increasingly clear that states will play a major role.
On Tuesday, Sen. Lamar Alexander, R-Tenn., and Sen. Patty Murray, R-Wash., announced that the Senate’s upcoming bipartisan healthcare hearings will feature testimony from “those closest to the problem”—state insurance commissioners and governors. The hearings are planned for Sept. 6 and 7.
“These state leaders understand full well the challenges facing healthcare today, and many have been outspoken about how the uncertainty caused by this administration has impacted the individual insurance market and therefore families’ premiums for 2018,” Murray said.
Alexander said the goal is to pass a “small, bipartisan and balanced” ACA exchange stabilization package before the Sept. 27 deadline for insurers to lock in their final plans for 2018. He also wants the package to fund cost-sharing reduction payments and “give states more flexibility in approving insurance policies” by improving section 1332 of the ACA.
Kasich, Hickenlooper join the fray
Two state governors, meanwhile, are preparing to offer up their own healthcare plan even before the Senate hearings begin. Ohio Governor John Kasich, a Republican, and Colorado Gov. John Hickenlooper, a Democrat, told Colorado Public Radio on Monday that they hope to unveil the plan within a week.
Previously, Hickenlooper and Kasich joined other state governors in speaking out against the House version of an ACA repeal-and-replace bill, arguing in a letter to Senate leaders that it “calls into question coverage for the vulnerable and fails to provide the necessary resources to ensure that no one is left out, while shifting significant costs to the states.”
That letter, as well as a Washington Post op-ed authored by Kasich and Hickenlooper, outlined a set of core principles for bipartisan healthcare reform—principles that their upcoming ACA stabilization plan will build upon, according to the CPR article. They include improving affordability, restoring stability to insurance markets, providing state flexibility, encouraging innovation and improving the regulatory environment.
Iowa submits stabilization plan
At least one state, though, isn’t waiting on Congress to rescue its individual health insurance market.
On Monday, Iowa officials submitted their application for federal regulators to approve the “Iowa Stopgap Measure,” a short-term stabilization plan formulated by the state’s insurance commissioner with the help of local health plans.
In the application (PDF), Iowa Gov. Kim Reynolds urged federal officials to quickly approve the measure, noting the state faces “an immediate collapsing market that could leave thousands without health insurance and the rest with 56% or higher premium rate increases.”
The plan, which requires the use of a section 1332 waiver, would redirect the $305 million in federal funding that currently goes toward the ACA’s premium tax credits and instead fund fixed, age- and income-based premium subsidies for consumers.
It would also use federal funds to implement a reinsurance program that will reimburse insurers for high-cost individuals who incur claims greater than $100,000 on an annual basis. As part of the program, insurers would have to agree to care-management protocols.
Special Report—How to fix the Affordable Care Act
Click to access FierceHealthcare-HowtofixtheAffordaleCareAct.pdf
As Congress prepares to get back to business, the industry is holding its collective breath to see if healthcare reform will fall off the agenda. It’s pretty clear that rushing through repeal, replace or repair legislation or letting the Affordable Care Act fail isn’t the answer. In this special report, FierceHealthcare’s editors—experts on the business of healthcare—outline ways to fix the nation’s healthcare system.
Medicaid Expansion Out of Pocket Spending Low Income
New Commonwealth Fund research out today demonstrates how states that expanded Medicaid eligibility have not only improved low-income residents’ access to health care but have also reduced what families must spend out of pocket on premiums, cost-sharing, and other related expenses.
Prior studies had shown that low-income residents of states that expanded Medicaid under the Affordable Care Act (ACA) are less likely to experience financial barriers to health care access. But the impact on people’s out-of-pocket spending had not been measured until now.
The new analysis, conducted by a team headed by Sherry Glied, dean of New York University’s Robert F. Wagner Graduate School of Public Service, found that the average low-income family in a Medicaid expansion state saves about $382 annually relative to a comparable family in a nonexpansion state. Moreover, low-income families in states that expanded Medicaid are less likely than their counterparts to have any out-of-pocket health care costs at all.
The authors say there was no statistically significant difference in outcomes for states that expanded through conventional Medicaid or through a waiver program.
Coverage expansion and primary care access
When you have a health problem, your first stop is probably to your primary care doctor. If you’ve found it harder to see your doctor in recent years, you could be tempted to blame the Affordable Care Act. As the health law sought to solve one problem, access to affordable health insurance, it risked creating another: too few primary care doctors to meet the surge in appointment requests from the newly insured.
Studies published just before the 2014 coverage expansion predicted a demand for millions more annual primary care appointments, requiring thousands of new primary care providers just to keep up. But a more recent study suggests primary care appointment availability may not have suffered as much as expected.
The study, published in April in JAMA Internal Medicine, found that across 10 states, primary care appointment availability for Medicaid enrollees increased since the Affordable Care Act’s coverage expansions went into effect. For privately insured patients, appointment availability held steady. All of the gains in access to care for Medicaid enrollees were concentrated in states that expanded Medicaid coverage. For instance, in Illinois 20 percent more primary care physicians accepted Medicaid after expansion than before it. Gains in Iowa and Pennsylvania were lower, but still substantial: 8 percent and 7 percent.
Though these findings are consistent with other research, including a study of Medicaid expansion in Michigan, they are contrary to intuition. In places where coverage gains were larger — in Medicaid expansion states — primary care appointment availability grew more.
“Given the duration of medical education, it’s not likely that thousands of new primary care practitioners entered the field in a few years to meet surging demand,” said the Penn health economist Daniel Polsky, the lead author on the study. There are other ways doctor’s offices can accommodate more patients, he added.
One way is by booking appointment requests further out, extending waiting times. The study findings bear this out. Waiting times increased for both Medicaid and privately insured patients. For example, the proportion of privately insured patients having to wait at least 30 days for an appointment grew to 10.5 percent from 7.1 percent.
The study assessed appointment availability and wait times, both before the 2014 coverage expansion and in 2016, using so-called secret shoppers. In this approach, people pretending to be patients with different characteristics — in this case with either Medicaid or private coverage — call doctor’s offices seeking appointments.
Improvement in Medicaid enrollees’ ability to obtain appointments may come as a surprise. Of all insurance types, Medicaid is the least likely to be accepted by physicians because it tends to pay the lowest rates. But some provisions of the Affordable Care Act may have enhanced Medicaid enrollees’ ability to obtain primary care.
The law increased Medicaid payments to primary care providers to Medicare levels in 2013 and 2014 with federal funding. Some states extended that enhanced payment level with state funding for subsequent years, but the study found higher rates of doctors’ acceptance of Medicaid even in states that didn’t do so.
The Affordable Care Act also included funding that fueled expansion of federally qualified health centers, which provide health care to patients regardless of ability to pay. Because these centers operate in low-income areas that are more likely to have greater concentrations of Medicaid enrollees, this expansion may have improved their access to care.
Other trends in medical practice might have aided in meeting growing appointment demand. “The practice and organization of medical care has been dynamic in recent years, and that could partly explain our results,” Mr. Polsky said. “For example, if patient panels are better managed by larger organizations, the trend towards consolidation could absorb some of the increased demand.”
Although the exact explanation is uncertain, what is clear is that the primary care system has not been overwhelmed by coverage expansion. Waiting times have gone up, but the ability of Medicaid patients to get appointments has improved, with no degradation in that aspect for privately insured patients.
Time Crunch Among Hurdles for Bipartisan Senate Push to Bolster ACA
https://morningconsult.com/2017/08/18/time-crunch-among-hurdles-bipartisan-senate-push-bolster-aca/
The leaders of a key Senate committee say they are cautiously optimistic about reaching a deal to shore up the Affordable Care Act’s individual marketplaces, but even with a bipartisan effort, it is far from certain whether they can hash out an agreement in time.
The Senate Health, Education, Labor and Pensions Committee leaders of both parties have set a self-imposed mid-September deadline for a bipartisan agreement. To keep lingering animosity from the Obamacare repeal fight from seeping into negotiations, Chairman Lamar Alexander has made clear that what he’s seeking is far from comprehensive.
The bill will have to be “small, bipartisan and balanced,” the Tennessee Republican said in a statement Wednesday.
Above all, Democrats want to make sure insurers continue to receive payments that help them cover out-of-pocket costs for some low-income patients. President Donald Trump has threatened to cut off the payments, and the administration has kept insurers on tenterhooks by making them only on a month-to-month basis.
Without the subsidies, known as cost-sharing reductions, some insurers warn they’ll be forced pull out of the ACA markets or hike premiums. The companies need certainty about payments at the latest by Sept. 27, the final deadline for them to decide whether to sell Obamacare plans in 2018.
If the committee can reach agreement next month, it would still be a challenge to get a bill through the full Senate and House before the key deadline for insurers. And Trump would still have to sign a bill into law that extends payments he is loath to continue.
The potential for chaos was highlighted this week when the nonpartisan Congressional Budget Office released a report estimating average premiums would rise 20 percent next year and the federal deficit would grow by $194 billion by 2026 if the administration stops paying.
While some conservative hard-liners want to cut off the CSRs, Alexander and other top Republicans have shown they’re willing to work with Democrats to have Congress extend the payments.
Sen. Patty Murray of Washington, the panel’s ranking Democrat, on Thursday called for quick action.
“People across the country are facing much higher premiums next year because of uncertainty driven by the Trump Administration, so I hope Republicans will join Democrats to act quickly to protect patients and families from paying more for care they need — and then continue working in a bipartisan way to make health care more affordable, accessible, and higher quality for all,” Murray said in a statement.
Democrats also want some sort of reinsurance program, an idea that has bipartisan support and would help insurers pay for their most expensive enrollees.
But in return for extending CSRs and including reinsurance, Republicans want to give states more authority over their health care systems, and Democrats could balk at some of their proposals.
Alexander has specifically pointed to changing the ACA’s 1332 waiver program, which allows states to opt out of key ACA regulations as long as it doesn’t lead to reduced coverage, skimpier benefits, more expensive insurance or a higher federal deficit.
In remarks to reporters earlier this month, Alexander noted a proposal that would eliminate all of those requirements besides increasing the federal deficit, in order to give states “more of an opportunity to approve insurance plans.” The plan, which was included in Senate Republicans’ health overhaul bill, would also bar the administration from rejecting a waiver as long as it doesn’t increase the federal deficit.
Democrats would likely oppose that proposal, wary of allowing states to undercut key Obamacare requirements without those other conditions in place.
Sen. Tim Kaine (D-Va.) said he’s interested in a proposal from Sens. Bill Cassidy (R-La.) and Susan Collins (R-Maine) to let states replace Obamacare’s most contentious provision — the mandate requiring people to purchase health insurance or pay a penalty — with a system that automatically enrolls individuals in low-cost coverage if they don’t do so on their own.
Backers of this approach argue it would offer comparable coverage to the individual mandate while being less intrusive, allowing people to opt out.
“I think that’s intriguing,” Kaine said earlier this month in a brief interview. “We ought to have that discussion, but you can’t blow the mandate without something to bring people into the program and do what insurance needs to do, which is to spread risk.”
But auto-enrollment has raised concerns among some liberal health care analysts, including over how to implement and administer such a system. The outstanding questions cast doubt on whether it could garner enough backing to be included in the stabilization bill.
Trump needs to stop sabotaging Obamacare — before it’s too late
THE CONGRESSIONAL Budget Office released on Tuesday yet another damning report on health care, this time highlighting the damage President Trump will do if he continues his Obamacare sabotage campaign. Over the next few weeks, during which the government and insurers must sort out what will happen to Obamacare insurance markets next year, everyone in the administration and every member of Congress must recognize that they have no more time to entertain repeal-and-replace fantasies. The fate of the health-insurance markets on which millions of people rely hangs on their willingness to accept reality.
The Trump administration has shown some flexibility. The Department of Health and Human Services last week offered insurers an extra few weeks to file rates for next year. Earlier, Alaska got $323 million in federal money to backstop its individual insurance market in a reinsurance arrangement that could drive down premiums and serve as a model for stabilizing insurance markets across the nation. Though Mr. Trump has repeatedly vowed to let Obamacare collapse, these moves show willingness to bolster, not undermine, the insurance markets that Obamacare created.
Yet the administration has stoked more uncertainty than it has allayed, leaving the health system in peril. The White House has been deciding month-to-month whether to keep important subsidy payments flowing to insurance companies — payments that were simply assumed during the Obama administration. Without these payments, insurers would have to jack up premiums or leave Obamacare markets next year. The CBO estimated Tuesday that average premiums would jump by 20 percent next year if the Trump administration pulled them. Moreover, because of how the payments interact with other elements of the health-care system, the government would end up losing money — $194 billion over a decade.
Though it would be irrational to subvert the health-care system and the budget, Mr. Trump has repeatedly threatened to do so. His officials also have taken steps in that direction, pulling advertisements meant to encourage people to enroll in health insurance, cutting programs that helped people sign up, railing about Obamacare’s “victims” and generally insisting, against the facts, that the law is a disaster. The administration’s moves to weaken the individual mandate, which requires all Americans to carry health coverage and underpins the Obamacare system, have led insurers to contemplate increasing premiums or leaving the system.
The president wanted and failed to overhaul Obamacare. That does not excuse him from faithfully executing the law. Unless Mr. Trump wants to be blamed for health-care chaos, the administration’s mixed messages must stop. Mr. Trump should commit to keeping the subsidies going permanently, to enforcing the individual mandate and to working with Congress on a bipartisan bill that would bolster insurance markets.
The broad strokes are clear: Democrats would ensure that subsidy payments are made permanent and Republicans would get more flexibility for states in administering Obamacare. More money should also go into reinsurance programs like Alaska’s. Though such a bill might come too late to hold down 2018 premiums, serious legislative activity could persuade insurers to stay in the market, riding out next year with the promise of a more stable situation in 2019.
All of this would be easier if the administration would commit to a strategy of stewardship, not sabotage.
110 ACOs to know | 2017
http://www.beckershospitalreview.com/lists/110-acos-to-know-2017.html
In its sixth edition, Becker’s Healthcare is pleased to highlight a variety of Medicare and commercial payer accountable care organizations led by hospitals, health systems, physician groups and other organizations.
Leavitt Partners, a Salt Lake City-based healthcare consulting firm, reports 934 active public and private ACOs in the United States during the first quarter of 2017 covering 2.2 million lives. Over the past year, 138 new ACOs began operation and 46 dropped their accountable care contracts, leading to an 11 percent growth year-over-year, according to Health Affairs.
Several ACOs represented on this list participate in the Medicare Shared Savings Program. Tracks 1 and 2 have limited provider risk; participants can benefit from shared savings but aren’t at risk for loss. MSSP Track 3, added in 2016, creates shared savings opportunities with greater risk. Track 3 ACO providers can share up to 25 percent of savings, but are at risk for loss. The most recently reported data for MSSP ACOs is the 2015 performance year.
CMS launched the Next Generation ACO Model in 2016, requiring providers to shoulder greater financial risk with the potential of earning more shared savings. The Next Generation ACOs qualify as advanced alternative payment models under the Medicare Access and CHIP Reauthorization Act’s Quality Payment Program in the 2017 reporting year. There are currently 45 participants in the Next Generation ACO Model.
These governmental contracts are in addition to commercial ACO arrangements, which at 715 in number, represent the plurality of all contracts, according to Health Affairs. Commercial ACOs tend to cover more lives than their Medicare counterparts.
Becker’s included ACOs on this list based on several factors, such as cost performance, participation in CMS ACO models and participation in innovative commercial agreements. ACOs are presented in alphabetical order. ACOs with multiple contracts are listed by the health system or provider group name.
HENRY KOTULA 