Tag Archives: Health Policy

Five Worrisome Trends in Healthcare

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https://www.medpagetoday.com/publichealthpolicy/healthpolicy/72001?pop=0&ba=1&xid=fb-md-pcp&trw=no

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A reckoning is coming, outgoing BlueCross executive says.

A reckoning is coming to American healthcare, said Chester Burrell, outgoing CEO of the CareFirst BlueCross BlueShield health plan, here at the annual meeting of the National Hispanic Medical Association.

Burrell, speaking on Friday, told the audience there are five things physicians should worry about, “because they worry me”:

1. The effects of the recently passed tax bill. “If the full effect of this tax cut is experienced, then the federal debt will go above 100% of GDP [gross domestic product] and will become the highest it’s been since World War II,” said Burrell. That may be OK while the economy is strong, “but we’ve got a huge problem if it ever turns and goes back into recession mode,” he said. “This will stimulate higher interest rates, and higher interest rates will crowd out funding in the federal government for initiatives that are needed,” including those in healthcare.

Burrell noted that 74 million people are currently covered by Medicaid, 60 million by Medicare, and 10 million by the Children’s Health Insurance Program (CHIP), while another 10 million people are getting federally subsidized health insurance through the Affordable Care Act’s (ACA’s) insurance exchanges. “What happens when interest’s demand on federal revenue starts to crowd out future investment in these government programs that provide healthcare for tens of millions of Americans?”

2. The increasing obesity problem. “Thirty percent of the U.S. population is obese; 70% of the total population are either obese or overweight,” said Burrell. “There is an epidemic of diabetes, heart disease, and coronary artery disease coming from those demographics, and Baby Boomers will see these things in full flower in the next 10 years as they move fully into Medicare.”

3. The “congealing” of the U.S. healthcare system. This is occurring in two ways, Burrell said. First, “you’ll see large integrated delivery systems [being] built around academic medical centers — very good quality care [but] 50%-100% more expensive than the community average.”

To see how this affects patients, take a family of four — a 40-year-old dad, 33-year-old mom, and two teenage kids — who are buying a health insurance policy from CareFirst via the ACA exchange, with no subsidy. “The cost for their premium and deductibles, copays, and coinsurance [would be] $33,000,” he said. But if all of the care were provided by academic medical centers? “$60,000,” he said. “What these big systems are doing is consolidating community hospitals and independent physician groups, and creating oligopolies.”

Another way the system is “congealing” is the emergence of specialty practices that are backed by private equity companies, said Burrell. “The largest urology group in our area was bought by a private equity firm. How do they make money? They increase fees. There is not an issue on quality but there is a profound issue on costs.”

4. The undermining of the private healthcare market. “Just recently, we have gotten rid of the individual mandate, and the [cost-sharing reduction] subsidies that were [expected to be] in the omnibus bill … were taken out of the bill,” he said. And state governments are now developing alternatives to the ACA such as short-term duration insurance policies — originally designed to last only 3 months but now being pushed up to a year, with the possibility of renewal — that don’t have to adhere to ACA coverage requirements, said Burrell.

5. The lackluster performance of new payment models. “Despite the innovation fostering under [Center for Medicare & Medicaid Innovation] programs — the whole idea was to create a series of initiatives that might show the wave of the future — ACOs [accountable care organizations] and the like don’t show the promise intended for them, and there is no new model one could say is demonstrably more successful,” he said.

“So beware — there’s a reckoning coming,” Burrell said. “Maybe change occurs only when there is a rip-roaring crisis; we’re coming to it.” Part of the issue is cost: “As carbon dioxide is to global warming, cost is to healthcare. We deal with it every day … We face a future where cutbacks in funding could dramatically affect accessibility of care.”

“Does that mean we move to move single-payer, some major repositioning?” he said. “I don’t know, but in 35 years in this field, I’ve never experienced a time quite like this … Be vigilant, be involved, be committed to serving these populations.”

 

 

Governor says hospital tax could cover Medicaid expansion

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https://www.charlotteobserver.com/news/article214337194.html

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Maine’s Republican governor is publicly laying out a proposed tax hike on hospitals to pay for voter-approved Medicaid expansion.

Gov. Paul LePage’s office says Medicaid expansion will offset a tax hike by decreasing charity care and bad debt. Maine’s hospital tax rate is 2.23 percent, and Rabinowitz said Maine could go up to six percent.

Maine Hospital Association lobbyist Jeffrey Austin previously told The Associated Press that Maine hospitals pay $100 million in annual taxes and would oppose an increase.

Mainers voted last fall to expand Medicaid to 80,000 low-income adults.

LePage’s administration is fighting litigation by advocates calling on the governor to stop blocking expansion. LePage vetoed legislation funding Maine’s share of expansion with surplus and tobacco settlement funds after he argued lawmakers must fund expansion without raising taxes.

 

 

This Tweet Captures the State of Health Care in America Today

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A nightmarish accident on a Boston subway platform on Friday — described in gory detail by a local reporter, Maria Cramer, as it unfolded and quickly retweeted by thousands — is one you might expect to see in an impoverished country.

In the face of a grave injury, a series of calculations follow: The clear and urgent need for medical attention is weighed against the uncertain and potentially monumental expense of even basic services, like a bandage or a ride to the hospital, and that cost, in turn, weighed against all the known expenses of living that run through any given head on any given day.

This discord, between agony and arithmetic, has become America’s story, too.

The United States spends vastly more on health care than other industrialized countries, nearly 17 percent of the nation’s gross domestic product in 2014, according to a report by the Commonwealth Fund, compared with just 10 percent of G.D.P. in Canada and Britain. But that disparity is not because Americans use more medical services — it’s because health care is far more expensive here than in other countries. One 2010 study by the Organization for Economic Cooperation and Development found that hospital costs were 60 percent higher in the United States than in 12 other nations.

And that cost is often passed on to patients, either in the form of deductibles and other out-of-pocket expenses or through ever-soaring insurance premiums.

The Affordable Care Act has improved access to health care, especially for lower-income families that now qualify for Medicaid or subsidies to buy private health insurance. Wider access, however, has not come cheaply for most people. As a result, many Americans, including those who are insured, have determined that they must avoid going to the hospital, visiting doctors or filling prescriptions that they need. A 2017 Kaiser Family Foundation survey found that 43 percent of people with insurance said that they struggled affording their deductibles, and 27 percent said that they put off getting care because of cost. Turning to GoFundMe and other crowdsourcing websites has become the norm in medical crises.

Whether the woman on the train platform received the medical attention she needed is unknown. Ms. Cramer said on Monday that she had not been able to get an update on the woman’s condition yet. Ms. Cramer went on to tweet that after several minutes had passed, an ambulance still had not arrived. Instead, fellow passengers tried to help. “One man stood behind her so she could lean against him,” she wrote. “Another pressed cold water bottles to her leg.”

Health care is a complicated problem, one exacerbated by the gridlock in Washington. But the trade-offs that everyday people are being asked to make, the calculations they are being forced to undertake in the scariest of situations, suggest that far too many of America’s politicians have placed too little value on the well-being of its citizens. Nothing will change until their fellow citizens step into the ballot box and insist on something better.

 

The “pleasant ambiguity” of Medicare-for-all in 2018, explained

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https://www.vox.com/policy-and-politics/2018/7/2/17468448/medicare-for-all-single-payer-health-care-2018-elections

Are we talking about single-payer health care or something else?

Democrats across the country are running on three simple words, recognizable to every American: Medicare for all.

“There’s no more popular brand in American politics than Medicare,” says Adam Green, co-founder of the lefty Progressive Change Campaign Committee (PCCC). “Our hope is that Democrats wrap themselves in the flag of Medicare in 2018.”

In Democratic primaries around the country, Medicare-for-all candidates are winning — from Kara Eastman in Nebraska to Katie Porter in Orange County, California, to Alexandria Ocasio-Cortez in the Bronx, the message is resonating.

“The system we have, the status quo is not acceptable,” Porter told me when I covered her primary race in May. “We’re questioning whether we can rely on major players, like health insurance companies, to continue to be reliable partners in delivering health care.”

Even before these candidates started winning, polling was showing that Medicare-for-all is really popular: 62 percent of Americans liked the sound of it in last November. Almost every single rumored 2020 candidate in the Senate has backed Sen. Bernie Sanders’s Medicare-for-all bill. It’s clear the idea is in ascendancy among Democrats.

But someday, a reckoning will come. When Democrats hold power again — especially control of Congress and the White House — they will be expected to actually deliver on these Medicare-for-all promises. And when that day arrives, the party will have to decide whether they want to blow up America’s current health care system to build something new or figure out a less disruptive path, but risk falling short of truly universal coverage.

So even now, there is some jockeying among Democrats to define those three little words.

What does “Medicare-for-all” actually mean?

As popular as Medicare-for-all is, the slightly more vexing question is what it actually means.

Historically, Medicare-for-all has meant single-payer health insurance, a national government-run program that covered every American and replaced private coverage entirely, similar to the government-run health care programs in Canada and some European countries.

Then-Rep. John Conyers (D-MI) first introduced the Expanded and Improved Medicare for All Act in 2003. Conyers has since been disgraced by sexual harassment allegations but the idea lives on. It’s now sponsored by Rep. Keith Ellison (D-MN) and it is still a single-payer proposal. So is Sanders’s Medicare-for-all bill, a cornerstone of his unexpectedly resonant 2016 presidential campaign.

But these days, other plans are falling under the Medicare-for-all umbrella. Some progressives, like Green, are even comfortable with the term being applied to the various proposals to allow all Americans buy into Medicare. Some of those plans used to be branded as a “public option”; they would not end private insurance that more than half of Americans get, usually through work, as a true single-payer would. But these plans would also not provide the same guarantee of universal coverage that a single-payer system does.

“For anybody who supports Medicare-for-all single payer, what better way to debunk the right wing lies than to allow millions and millions of Americans to voluntarily opt into Medicare and love it?” Green told me in our interview. “As a political strategy, having Medicare-for-all be a broad umbrella where any candidate can embrace some version of it… that moves the center of gravity in the Democratic party.”

In 2018, with control of Congress at stake, nobody is taking up arms to insist that their version should be orthodoxy. What we know for certain is that Medicare-for-all is popular, and so Democrats of all stripes want to campaign on it. Governing comes later.

What does the public think about Medicare-for-all versus single-payer health care?

Ultimately, the direction the Democratic party goes in may have a lot to do with how far the public is willing to go.

One chart from the Kaiser Family Foundation, the gold standard for health policy polling, sums up why there is any debate at all about the meaning of Medicare-for-all.

Medicare-for-all gets nearly two-thirds support, but a “single-payer health insurance system” is a little more divisive: 48 percent have a positive reaction, and 32 percent have a negative reaction; the gap between favor and disfavor closes considerably. Medicare buy-ins poll the highest, with the support of three-fourths of Americans, including 6 out of 10 Republicans.

You could absolutely argue these numbers still seem pretty strong for single-payer described as such, given the conventional wisdom that such a plan is unworkable. But it is undoubtedly true that Medicare-for-all, as a slogan, is more popular — as are some of these more incremental policies, like giving people the option of buying into Medicare.

The “pleasant ambiguity” of Medicare-for-all, explained

Back in 2012, a group of progressive activists and Democratic lawmakers got together to talk about what they would do if the Supreme Court ruled the Affordable Care Act unconstitutional. That looked like a real possibility, and they agreed on a new campaign to keep pushing for universal health care.

Democrats planned to run on a platform of Medicare-for-all if the Court struck the law down. At that point, the Conyers single-payer bill had been around for nearly a decade, but the PCCC’s Green says that on that day and in that room, some people heard Medicare-for-all and thought of a single-payer system. Yet others heard the same thing and thought of something that looks more like a public option. From his perspective, those different ideas aren’t a problem.

“There is a pleasant ambiguity and more of a north star goal nature around Medicare-for-all,” Green said. “This really does not need to be a huge intra-party battle. Why get in the weeds during the campaign?”

Voters themselves seem to like the sound of Medicare-for-all, even if they themselves don’t always agree on what it means. BuzzFeed’s Molly Hensley-Clancy reported on this phenomenon while covering Eastman’s campaign in Nebraska ahead of the May primary:

[C]onversations with more than two dozen Omaha voters reveal a dynamic that polling, too, has begun to capture: When some moderate and left-leaning voters say “Medicare for All” sounds like a pretty good idea, they aren’t actually thinking about single-payer health care. Instead, they’re thinking about simply expanding the program to include more seniors or children, or offering a public option that people can buy into.

On one warm May day a week from the primary, Phil, a devout liberal, told Eastman the story of his wife’s brain cancer — rejected by Medicaid, and still too young for Medicare, they’ve barely been able to afford pricey experimental treatments.

He likes the sound of Medicare for All, he said, but wouldn’t want everyone to be part of a single-payer, government-run system. “I wouldn’t want one system,” he told BuzzFeed News. “I wouldn’t want that.”

We heard similar ambiguity when Vox conducted some focus groups with Hillary Clinton voters in suburban Washington, DC, last fall. Those voters, particularly the ones who currently had their own insurance through work, liked the idea of having a choice, having an option. They also liked the sound of Medicare-for-all, but a top-to-bottom overhaul of the American health care system made them nervous.

“To me, [single-payer] sounds like it’s somehow complete overhaul of everything, whereas Medicare-for-all sounds like warming people up to the idea using the structure that’s already in place to deliver that care,” Dennis, a 34-year-old Hillary Clinton voter in Bethesda, told us.

One of the things that made Democrats the most nervous about single payer is how political health care has become. They see how Trump has attacked Obamacare, and they see future Republican administrations meddling with single-payer health care as a real possibility. That could be a sticking point for some Democratic voters, especially those who are better off and already get good insurance through work.

Medicare-for-all is uniting Democrats for now — but it could divide them later

That explains why there’s this fledgling competition over what Medicare-for-all is really describing.

The best example might be the health care plan from the Center of American Progress, which is, tellingly, called “Medicare Extra For All.” It’s a seriously ambitious plan, one that would achieve universal coverage through a combination of government plans and private insurance, while preserving employer-based insurance for those who want it. But it is not single payer. And it is notably produced by an organization closely aligned with the Democratic establishment.

“To the extent there will be moments where we have to bring clarity to what Medicare-for-all means for us on the progressive side of the house, compared to other people who want to dance around the issue, we will do that,” Nina Turner, who leads the Sanders-affiliated Our Revolution, told me. “For us, at Our Revolution, it is Medicare for all, the whole thing, for everybody in this country.”

The scars from the Obamacare reveal themselves in this debate. For all the health care law has achieved, it also showed the limits of incrementalism. Even Medicaid expansion, the closest thing the law had to a single-payer pilot, was undermined by the Supreme Court by allowing Republican-led states to refuse it. The Obamacare insurance markets have been susceptible to sabotage from Republicans in Congress and the Trump administration.

Yes, the uninsured rate has reached historic lows under Obamacare, but 10 percent of Americans still lack coverage. Democrats will be faced again, at some point, with a choice between a more incremental approach, like the Medicare public options introduced by some Democrats in Congress, or a sweeping overhaul like single-payer. They can put it off for a while and campaign, as Green suggests, on whatever Medicare-for-all means to voters. But eventually that debate will need to be had.

Its outcome is far from certain. Eastman, one of Medicare-for-all’s most notable champions so far in 2018, described the dilemma perfectly.

She unambiguously supports single-payer Medicare-for-all. But “with the current Congress, with the current president, is that feasible?” she said. “I think you have to be practical about what’s happening in our country.”

Yet even if she recognizes the political realities of the moment, she wants Democrats to be bolder in their agenda.

“We have to stop backing off from this issue,” Eastman said. “That’s one of the problems with the ACA. It didn’t go far enough.”

 

 

 

 

 

 

How Kennedy’s SCOTUS Replacement Could Open the Door to Medicaid Cuts

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http://www.thefiscaltimes.com/2018/07/03/How-Kennedy-s-SCOTUS-Replacement-Could-Open-Door-Medicaid-Cuts

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Axios’ Caitlin Owens says the next Supreme Court justice could give states more power to cut Medicaid. The legal issue in question is whether private health care providers can sue over Medicaid payment rates. The Supreme Court ruled in 1990 that they could, and Anthony Kennedy dissented in that case — but took less of a hard-line stance than other conservatives. He “was willing to leave the courthouse doors open in Medicaid cases, whereas the conservative majority is willing to shut it – I mean, really slam it,” Sara Rosenbaum, a George Washington University law professor, told Axios.

Kennedy’s replacement could provide a fifth vote to prevent private providers from suing, giving states plenty of leeway to make cuts to their Medicaid programs without the threat of legal action.

Owens notes that Kansas and Louisiana have asked the Supreme Court to consider whether they can exclude Planned Parenthood from their Medicaid programs, and whether the group can challenge that exclusion.

 

 

More Americans Paid for ACA Plans This Year — and More Are Getting Priced Out

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https://www.thefiscaltimes.com/2018/07/03/More-Americans-Paid-ACA-Plans-Year-and-More-Are-Getting-Priced-Out

 

President Trump has declared that Obamacare is finished, dead, gone, essentially repealed. And yet, despite the administration’s efforts to undermine the law’s marketplaces, the number of Americans who enrolled in and started paying for Affordable Care Act plans grew slightly this year, according to reports released Monday by the Centers for Medicare and Medicaid Services (CMS).

At the same time, rising premiums are taking a toll, forcing many middle-income Americans — individuals making more than about $48,000 a year, or families of four making more than about $100,000 — to drop coverage. “Taken together, these reports show that state markets are increasingly failing to cover people who do not qualify for federal subsidies even as the Exchanges remain relatively stable,” CMS said.

Here’s a look at what the new reports show:

* While the total number of people who picked a plan for 2018 fell, the number of people who paid for coverage rose from 10.3 million in February 2017 to 10.6 million this past February, an increase of about 3 percent. “The increase is striking because it happened even though federal health officials last year slashed ACA funding to grass-roots groups that help consumers sign up for coverage, cut advertising and other outreach activities by 90 percent, and shortened the enrollment period by half,” writes Amy Goldstein at The Washington Post.

* CMS argued that, based on historical trends, a “significant number” of people will wind up dropping coverage during the year even after making their initial payments. Of the 10.3 million who paid for their plans as of March 15, 2017, only 8.9 million were still in those plans by the end of the year. “This is likely caused by consumers struggling to pay premiums as costs continue to increase,” the CMS report said.

* A larger share of enrollees has been getting federal subsidies. In 2014, the first year Affordable Care Act plans became available, 55 percent of those enrolled in individual market plans on or off the new Obamacare exchanges got financial help, according to Bloomberg. Last year, 62 percent did. In all, more than 8 million people got subsidies last year, while 5 million bought individual plans without financial help. “When premiums rise a lot, a lot more people become eligible for subsidies,” Matthew Fiedler, a fellow at the U.S.C.-Brookings Schaeffer Initiative for Health Policy, told The New York Times.

* As insurance prices rose by an average of 21 percent last year, signups among people who did not qualify for subsidies fell by 1.3 million — a drop of 20 percent compared with 2016. Subsidized enrollees fell by just 3 percent. “These reports show that the high-price plans on the individual market are unaffordable and forcing unsubsidized middle-class consumers to drop coverage,” CMS Administrator Seema Verma said in a statement. Trump administration policies may have played a part in the decline, too, and some people may have stopped buying their own insurance because they found jobs with employer coverage. “But it’s reasonable to think that most of the attrition can be attributed to the spike in prices, as the Trump administration concludes,” writes Margot Sanger-Katz of The New York Times.

What it all means: “The individual health insurance market under the ACA is financially sustainable as subsidies rise to match premium increases,” Larry Levitt of the Kaiser Family Foundation tweeted. “However, the lack of affordable insurance for middle-class people ineligible for subsidies does not seem politically sustainable.”

 

 

 

 

 

 

What’s Driving Health Care Costs?

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https://www.healthaffairs.org/do/10.1377/hblog20180625.872430/full/?utm_term=Read%20More%20%2526gt%3B%2526gt%3B&utm_campaign=Health%20Affairs%20Sunday%20Update&utm_content=email&utm_source=2018-06-24&utm_medium=email&cm_mmc=Act-On%20Software-_-email-_-ACA%20Round-Up%3B%20Health%20Care%20Costs%3B%20Medicaid%20Expansion%3B%20Prescription%20Drug%20Monitoring%20Programs-_-Read%20More%20%2526gt%3B%2526gt%3B

Value-based payment (VBP) models are an effort to rein in the growth of health care costs and improve quality. However, it’s unclear what overall impact VBP models are having on health care costs. Even though health care is provided at the local level, most evaluations examine health care spending at the national level. To address this disconnect, we conducted quantitative and qualitative market-level assessments. Our goals were to examine the impact of population-based, value-based care within a market; identify what measurable factors were associated with differing costs; and understand how business leaders are thinking about value-based care and cost reduction.

Leavitt Partners, the Healthcare Financial Management Association (HFMA), and McManis Consulting, with participation from Mark McClellan at Duke University, conducted three mixed-methods studies:

  1. “Growth of Population-Based Payments Is Not Associated with a Decrease in Market-Level Cost Growth, Yet” examined the impact of population-based VBP on per-beneficiary-per-year (PBPY) health care spending and quality of care. The study used growth curve modeling and fixed-effects regression analyses of Medicare and commercial claims data.
  2. “Market Factors Associated with Medicare Costs and Cost Growth” examined which market factors are correlated with PBPY health care costs and cost growth within a market using growth curve modeling. The study used and aggregated multiple data sets from public and private sources.
  3. “What Is Driving Total Cost of Care? An Analysis of Factors Influencing Total Cost of Care in U.S. Health Care Markets” combined qualitative interviews conducted during site visits of nine markets and the quantitative findings from the studies above to understand factors that may be influencing total cost of care in US health care markets.

Key findings from the studies include:

  • Based on data from 2015, there was no association between an increase in population-based VBP and slowing of health care costs in a given market. Our study did not include episode-based payments.
  • Health care leaders across markets believe further changes to payment and delivery models are coming. Less clear is what, or who, will be the catalyst to push further change.
  • Some stakeholders expressed stronger support for other types of VBP models, including episode-based models and models that address the needs of specific patient groups.
  • The question of “what type of competition” in a market may be more important than “how much” competition. Lower-cost markets featured competition among a few health systems with well-aligned physician practices and geographic coverage across their market.
  • Lower-cost markets appear to benefit from organized mechanisms, including state-sponsored or endorsed reporting agencies, for more transparent sharing of information on provider quality and costs.Based on quantitative and qualitative evidence, the studies contribute to our understanding of the dynamics of competition, integration, and transparency on health care costs in a market. Below, we summarize findings from the three mixed-method studies and provide some policy implications.

Population-Based VBP Models Are Not Lowering Market-Level Health Care Costs … Yet

VBP dates back to 2005 with the Physician Group Practice Demonstration. The Affordable Care Act (ACA) significantly accelerated the proliferation of VBP models with the creation of the Medicare Shared Savings Program(MSSP) and the Center for Medicare and Medicaid Innovation, which was tasked with developing and testing innovative new models. Commercial VBP arrangements have also taken hold in the years since the ACA’s passage.

Given the growth of VBP, we wanted to examine whether, in the first few years following the ACA, these models were influencing the total cost of care. We used Medicare data from 2012 to 2015 and commercial data from 2012 to 2014 to assess the early impact of these models. We restricted our study to population-based VBPs, which included models with upside risk only (shared savings), both upside and downside risk, and global budgets, but excluded episode-based (bundled) payments.

We did not find a statistical relationship between the level of penetration of population-based VBPs in a market and a decline in health care costs for Medicare or commercial payers. Nor did we find an improvement in quality. When we limited our analysis to just those markets with higher levels of population-based VBP penetration (at least 30 percent), our results suggested a very modest, not statistically significant, market-level decrease in cost growth. Despite this null finding, our results provide an important baseline for future research.

Possible Explanations

There are several potential explanations for the null findings. For one, our study period (2012–15) may simply have been too early to see signs of population-based VBP lowering health care costs. Although today 561 MSSP accountable care organizations (ACOs) (the largest of Medicare’s ACO programs) cover 10.5 million beneficiaries, at the beginning of our study period in 2012 and 2013, only 220 MSSP ACOs covered 3.2 million beneficiaries. Many interviewees told us not enough lives were covered under VBP. Indeed, in some markets, less than 1 percent of lives were part of a VBP arrangement.

Second, although participation in population-based VBP models is growing, few models involve the provider taking on downside risk. As of 2018, the majority (82 percent) of MSSP ACOs were in the non-risk-bearing Track 1, which means they share in savings if they spend less money than their assigned benchmark, but they will not incur financial losses if they spend more than the benchmark. Our site visits found that although different markets had varying levels of population-based VBP activity, no market had significant numbers of providers participating in downside risk. Several interviewees stressed the need to take incremental steps to more risk.

Fee-for-service payment remains quite profitable for many providers and health systems. Even for those that have begun to take on risk-based contracts, fee-for-service payment represents the majority of total revenue. As long as the status quo remains lucrative, it’s difficult to make the business case for why a provider should undertake the effort to switch to a value-based focus that may lead to a reduction in use and total revenue.

Still, several interviewees said they believed the move toward paying for value would continue, even if there’s some uncertainty over whether Medicare or private payers will lead the movement. It’s possible that when VBP models outweigh fee-for-service payments in a market, we’ll reach a “tipping point” and health care cost growth will decline. Many interviewees expressed enthusiasm for other VBP models, such as those based on episodes of care (bundled payments) and those designed for specific populations (for example, the frail elderly). These models may make more sense for specialty providers who perform a certain type of procedure or care for a certain type of patient.

Other Market Factors

If these initial population-based VBPs results don’t show a relationship to health care cost growth, then which market-level factors do correlate? For our second quantitative analysis, we used a variety of public and private data sources to examine the relationship among several market-level factors beyond value-based payment and Medicare costs and cost growth between 2007 and 2015. All the factors together explained 82 percent of variation in baseline Medicare costs (Exhibit 1). 

The prevalence of chronic diseases was the most influential predictor of market costs, accounting for 41.5 percent of the variance. Hospital quality metrics, market socioeconomic status, and the concentration of hospitals and insurers also helped explain market-level costs.

Using these same factors to predict Medicare cost growth was less fruitful, explaining only 27 percent of the variation in Medicare cost growth—substantially less than the 82 percent of baseline costs. As Exhibit 2 shows, a much weaker association exists between chronic disease prevalence and Medicare cost growth. Significant additional research should be done to identify factors that predict cost growth.

These findings matter for several reasons. First, they reinforce efforts currently underway to contain costs, including strategies to prevent and better manage chronic conditions, reduce hospital readmissions, and reduce the number of individuals without insurance. Second, although we know less about what drives health care cost growth in a market, meaningfully reducing spending in a market relies on developing strategies that target cost growth, instead of baseline costs. More research that focuses on what’s driving cost growth is needed.

The Role Of Competition And Transparency On Costs

The interviews we conducted add insights into these market-level findings. We identified two distinguishing characteristics of higher- and lower-cost markets: type of competition in the market and degree of transparency in the market. We recognize that while there are some common lessons, health care markets differ significantly and their approaches to care, costs, and VBP models will vary.

Competition

We know competition can help drive down costs and increase quality in health care markets. However, how much competition, and what type, seems to make a difference. For example, we found that the lower-cost markets in our nine site visits had at least one integrated delivery system. Consolidation in these markets had resulted in two to four health systems with geographic coverage across the market. In these markets, physicians were generally employed by the health system or worked in close alignment with it. Health plan competition matters as well, particularly with respect to innovation in new payment and care delivery models. Portland, Oregon, and Minneapolis-St. Paul, Minnesota, two of the lowest-cost markets, both had competitive health plan landscapes.

Conversely, the markets we visited with less integration and seemingly more provider competition actually had higher costs. These included Los Angeles, California (which had higher Medicare costs only), Baton Rouge, Louisiana, and Oklahoma City, Oklahoma. One reason for this may be that there is less focus on addressing unnecessary use in these markets.

Transparency

Transparency is often cited as a strategy that will help contain costs. Similar to competition, the type of transparency effort matters. We found that some lower-cost markets seemed to benefit from organized transparency mechanisms, including state-sponsored or endorsed reporting agencies and employer coalitions that made information on provider quality and costs publicly available. For example, in 2005, the Minnesota Medical Association and health plans in the state together formed MN Community Measure, a nonprofit organization tasked with the collection and dissemination of data on the quality and cost of providers across the state. Today, providers are required to submit data to the organization. Our interviewees expressed optimism but acknowledged more work is needed to optimize consumer-oriented transparency tools, which research has so far shown to have had only minimal use.

Policy Recommendations

Our research led us to three primary policy recommendations to help improve health care quality and lower costs (for additional ones, see the fullstudies).

  1. Continue movement toward payment models that increase financial incentives to manage total cost of care and closely monitor the impact of doing so because our findings show that the majority of payments in a market continue to flow through fee-for-service, instead of value-based arrangements. Experiments should continue with population-based VBP models but should not be confined exclusively to these models. Episode-based payment models, for example, may be better suited to certain types of providers who perform a certain procedure (for example, a knee replacement) instead of care for a general population of patients.
  2. Balance the benefits of competition with the benefits of integration. The lower-cost markets we studied had competition among two and four systems with well-organized provider networks that had been developed through vertical integration or strong alignment of physician practices. Most of the lower-cost markets also had an integrated delivery system—with vertically integrated health plan, hospital, and physician capabilities—as a competitor in the market.
  3. Support more transparent sharing of information on health care cost and quality within markets. Lower-cost markets in the qualitative study had organized mechanisms for the sharing of information on health care cost and quality, whether through employer coalitions, statewide reporting agencies, or both.

Although differences exist among each health care market, all markets can act to improve quality and reduce costs. Our studies suggest several actions different stakeholders in each market can take to improve care for their populations.

 

 

With Roe in the Balance, Two Republicans Hold High Court in Their Hands

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Justice Anthony M. Kennedy’s retirement announcement was less than a day old when liberal activists rallied on the steps of the Supreme Court on Thursday, invoking the names of two Republican senators who, they believe, hold the future of Roe v. Wade in their hands.

“Remember Susan Collins! Remember Lisa Murkowski!” Neera Tanden, president of the liberal Center for American Progress, exhorted the crowd. “If they claim to be pro-choice, choice is on the line with this decision.”

Ms. Collins, of Maine, and Ms. Murkowski, of Alaska, are powerful — and rare — creatures in Washington: moderate Republican women who favor abortion rights and are unafraid to break with their party. Their no votes helped sink the Republican repeal of the Affordable Care Act last year; both objected vociferously to a provision that would have stripped funding from Planned Parenthood Federation of America, the women’s health and reproductive rights organization.

Now, with President Trump’s pledge to nominate a “pro-life” jurist to replace the retiring Justice Kennedy, the senators are under pressure as never before. Much like Justice Kennedy, they are swing votes — not in a court case, but in a coming confirmation battle that will shape the Supreme Court, and American jurisprudence, for generations to come.

The math in the Senate tells the tale. With Senator John McCain, Republican of Arizona, undergoing cancer treatment, Republicans have the slimmest of majorities: 50-49. If every Democrat votes against a Trump nominee, it would take just one Republican defector to block confirmation. And with a filibuster no longer an option, Democrats are powerless to block a nominee on their own.

So within minutes of Justice Kennedy’s announcement on Wednesday, Democrats and their allies began looking toward Ms. Collins and Ms. Murkowski.

So did the White House. Ms. Collins and Ms. Murkowski were among a bipartisan group of six senators who met separately with Mr. Trump on Thursday night to talk about the court vacancy. Earlier Thursday, Ms. Collins said in an interview that she had taken a call from the White House counsel, Donald F. McGahn II, and that she urged him to look beyond the list of deeply conservative jurists that Mr. Trump has promised to pick from — a significant request, given that Senator Chuck Schumer of New York, the Democratic leader, has declared that Democrats will not back any nominee on that roster.

Mr. Schumer has also made clear that he will make the fate of Roe v. Wade, the 1973 landmark decision that established a constitutional right to abortion, the centerpiece of Democrats’ strategy to block any nominee they consider extreme. Ms. Collins, choosing her words carefully, suggested Roe would figure into her decision-making.

“I believe in precedent,” she said. “In my judgment, Roe v. Wade is settled law, and while I recognize that it is inappropriate to ask a nominee how he or she would rule in any future case, I would certainly ask what their view is on the role of precedent and whether they considered Roe v. Wade to be settled law.”

Both senators are well aware that, no matter how they vote, one side is going to be unhappy. Ms. Murkowski acknowledged feeling the weight of the moment.

“There’s pressure because of the gravity of such a nomination,” Ms. Murkowski told Politico. “I am not going to suggest that my opportunity as a senator in the advise-and-consent process is somehow or other short-cutted just because this is a Republican president and I’m a Republican.”

Senator Chris Murphy, Democrat of Connecticut, framed the situation for Ms. Murkowski and Ms. Collins this way: “This is a legacy vote. Very few people in the Senate, even those who’ve been here for a long time, will cast a more important vote than this.”

Liberal activists and Mr. Schumer have demanded that a nominee not be confirmed until after the November election, but Senator Mitch McConnell, the Republican leader, has promised a speedy process, with a confirmation vote by fall.

For Democrats, unified opposition will be difficult — especially in an election year when 10 Senate Democrats are up for re-election in states won by Mr. Trump. Three of those Democrats — Heidi Heitkamp of North Dakota, Joe Donnelly of Indiana and Joe Manchin of West Virginia — voted last year to confirm Justice Neil M. Gorsuch. So did Ms. Collins and Ms. Murkowski.

Since then, Justice Gorsuch has emerged as a consistent vote in the high court’s conservative bloc.

To say that tensions are high in the Senate around Supreme Court nominees would be an understatement. The wounds of 2016 remain raw and open. Democrats are still angry that Republicans, led by Mr. McConnell, blockaded President Barack Obama’s nominee, Judge Merrick B. Garland of the Federal Appeals Court here, by denying him a hearing — and giving Mr. Trump opportunity to put Justice Gorsuch on the court.

Ms. Murkowski sided with leadership then. But Ms. Collins broke ranks and called for Judge Garland to have a hearing — a moment she recalled on Thursday. “This is not a pleasant situation,” she said, referring to the Kennedy vacancy. “But it’s not strange to me.”

Neither Ms. Murkowski nor Ms. Collins face re-election this year, which gives them a measure of freedom in how they vote. Still, they are likely to face pressure back home. Eliza Townsend, executive director of the Maine Women’s Lobby, a women’s rights group, said her organization intended to step up its contacts with Ms. Collins.

“Maine people understand that this is for all the marbles,” she said. “This is a critical, critical moment.”

Both Ms. Murkowski and Ms. Collins have long been independent figures in the Senate. In 2010, when Ms. Murkowski ran for re-election, she lost in a primary to a Tea Party Republican. Instead of bowing out, she ran a write-in campaign — posing a challenge to voters who needed to know how to spell “Murkowski” — and won. The victory effectively freed her from party constraints.

Ms. Collins has a reputation for working across the aisle. In 2013, she led an effort among Senate women, including Ms. Murkowski, to put an end to that year’s government shutdown. As co-chairwoman of a bipartisan group called the “Common Sense Coalition,” she helped end this year’s shutdown as well.

Last week, she helped put together two ideological opposites, Senator Ted Cruz, Republican of Texas, and Senator Dianne Feinstein, Democrat of California, to work on immigration legislation.

Conservative advocates said Thursday that they were confident the two would confirm the president’s pick.

“We’ve seen from their statements that they both are very concerned about a judge that’s going to be fair, impartial and abide by the rule of law, and I think that’s exactly what we’re going to get: someone they both are just not comfortable with but very happy to vote for,” said Carrie Severino, chief counsel and policy director of Judicial Crisis Network, a conservative advocacy group.

With the Senate gone for its July 4 recess, Ms. Collins and Ms. Murkowski may get a little break. But once Mr. Trump names a nominee, the pressure will rise.

“These are two women who have been very clear, over many decades, that our constitutional right that protects women’s most important right of privacy — their right to reproductive rights — is important to them,” said Judith L. Lichtman, former president of the National Partnership for Women and Families, and a longtime Washington advocate for women’s rights. “And now they have a chance to prove it.”

‘Everyone is focused on Lisa and Susan’: The two most powerful senators in the fight to replace Kennedy

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https://www.washingtonpost.com/politics/everyone-is-focused-on-lisa-and-susan-the-two-most-powerful-senators-in-the-fight-to-replace-kennedy/2018/06/28/d7f7f72e-7ae6-11e8-93cc-6d3beccdd7a3_story.html?noredirect=on&utm_term=.191014524354

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The Democrats’ hopes of sinking President Trump’s upcoming nominee for the Supreme Court hinge on a pair of Republican women who have broken with their party over abortion and dismantling the Affordable Care Act.

With the GOP holding a 51-to-49 majority in the Senate, the votes of Sens. Lisa Murkowski (Alaska) and Susan Collins (Maine) will almost certainly be needed for Trump’s eventual nominee to be confirmed, making them the most influential senators in the battle to replace Justice Anthony M. Kennedy, who announced Wednesday that he is retiring.

Both will be the target of intense lobbying as Trump is expected to put forward a pick who would shift the court rightward, putting in play issues such as abortion, gay rights and the government’s role in health care.

The two senators are trying to play down their influence as the frenzy over the Supreme Court opening grows and the pressure on them builds.

“It’s been kind of interesting in this firestorm. Afterward, everyone is focused on Lisa and Susan,” Murkowski said in an interview Thursday. “If I were John or Jerry or Bill, I’d say, ‘Wait a minute. How come I’m not being viewed as an important voice in this process?’ ”

But Murkowski and Collins are the rare elected Republicans in Washington who support abortion rights and voted against repealing the Obama-era Affordable Care Act — issues Democrats are using to frame the battle over the Supreme Court nominee.

“A woman’s right to control her body is at stake with this next nominee,” said Sen. Dianne Feinstein (Calif.), who as the top Democrat on the Judiciary Committee will lead her party’s scrutiny of Trump’s nominee. Asked how much Collins and Murkowski should weigh abortion in their decision, Feinstein said, “That’s up to them. But for me, it’s huge. Because I know what life was like before and most young women don’t.”

Murkowski called the future of Roe v. Wade — the 1973 decision that legalized abortion nationwide — a “significant factor,” but she stressed that in no way will that landmark ruling be the sole factor for her.

“And I don’t think it should be the only factor for anybody,” Murkowski said. “It’s not as if those are the only matters that come before the Supreme Court.”

Collins said Thursday that although she wouldn’t ask Trump’s pick how he or she would rule on specific issues, she always presses judicial nominees about their views on legal precedent.

“I do get a sense from them on whether or not they respect precedent,” Collins said. “And from my perspective, Roe v. Wade is an important precedent and it is settled law.”

Republicans, well aware that Democrats will try to pin down Trump’s pick on contentious issues, are already making the case that any nominee should abide by the standard Justice Ruth Bader Ginsburg used during her 1993 hearings: To give “no hints, no forecasts, no previews” on how they might rule.

“I think the only thing that’s going to influence those two very good senators is . . . how they perform in the hearing,” said Senate Judiciary Committee Chairman Charles E. Grassley (R-Iowa). “Because Collins and Murkowski would obviously respect the Ginsburg rule.”

The scrutiny the two senators face is far from unfamiliar. Collins is one of a dwindling core of moderate Republicans who have been willing to defect from the party on contentious issues, including abortion and guns. And like Collins, Murkowski has an independent streak — one that helped her win reelection in 2010 through a write-in campaign after she lost in the GOP primary. Both senators also opposed the nomination of Betsy DeVos as education secretary, forcing Vice President Pence to cast the tie-breaking vote to confirm her.

But they have been consistent “yes” votes on Trump’s picks for federal courts.

The two senators have voted on five of the most recent Supreme Court justices, with Collins serving as a reliable “yes” while Murkowski rejected both of President Barack Obama’s nominees: Elena Kagan and Sonia Sotomayor.

Of the 25 names Trump has listed as potential justices, 17 have been confirmed by the Senate for federal judgeships, while two are pending. Murkowski has supported all of the candidates nominated during her time in the Senate while Collins voted against one: Judge William Pryor of the Court of Appeals for the 11th Circuit.

Groups that favor abortion rights have begun flooding Senate offices with phone calls and are widening the universe of targeted Republicans beyond Collins and Murkowski to Sen. Dean Heller (Nev.), the most politically vulnerable Senate Republican on the ballot this fall.

Ilyse Hogue, the president of NARAL Pro-Choice America, said calls from her group’s activists to Senate offices in the 24 hours after Kennedy’s retirement announcement Wednesday were three times the volume of the calls that resulted immediately after Neil M. Gorsuch was nominated in January 2017 to replace the late Antonin Scalia.

“Sens. Murkowski and Collins have already laid down the marker saying that they stand by Roe, they believe in legal access to abortion,” Hogue said. “It’s about upholding their word through this vote, and we’re going to make sure that the public support is there for them in their states and that there will be a lot of frustration and anger if they don’t.”

Public polling indicates a nation split over abortion. The most recent nonpartisan survey to ask whether the procedure should be legal in all or most cases is a Public Religion Research Institute poll in March, which found 54 percent of respondents saying that abortion should be legal in most or all cases vs. 43 percent saying it should be illegal in most or all cases.

Collins and Murkowski — as well as a small cadre of moderate Democratic senators — are likely to receive heavy attention from Trump administration officials as the White House tries to secure support for the president’s yet-to-be-named nominee.

The two Republicans, as well as Grassley and the three Democrats who voted in favor of Gorsuch, met with Trump on Wednesday evening at the White House to discuss the vacancy, White House press secretary Sarah Huckabee Sanders said.

Murkowski already had one suggestion for the administration: Consider people who may not be on the short­list crafted during Trump’s presidential campaign with heavy input from the Federalist Society. She said she wants a chance to weigh in on potential candidates.

“I don’t know how we got so wedded to that list. That was not created by senators here,” she said.

Marc Short, the White House’s director of legislative affairs, noted that he, Pence and White House counsel Donald McGahn had met with Collins, Murkowski and swing Democrats such as Sens. Joe Donnelly (Ind.) and Joe Manchin III (W.Va.) as they considered Gorsuch last year.

“I think that you will see continued White House outreach,” Short said. “Stay tuned on the specifics.”

 

 

‘What The Health?’ Podcast Turns 1. Justice Kennedy Retires. Now What?

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The retirement of Supreme Court Justice Anthony Kennedy has triggered a political earthquake in Washington, as Republicans see a chance to cement a conservative majority and Democrats fear a potential overturn of abortion rights and anti-discrimination laws, and even — possibly — challenges to the Affordable Care Act. Kennedy has been the deciding vote in dozens of cases over his long career on the high court, mostly siding with conservatives but crossing ideological lines often enough that liberals see him as the last bulwark against challenges from the right to many policies.

The Supreme Court made other health news this week, ruling that California cannot require anti-abortion “crisis pregnancy centers” to post signs informing women of their right to an abortion and telling them that financial help is available.

And this is a special week for us. It’s our first anniversary. This week’s panelists for KHN’s “What the Health?” are Julie Rovner of Kaiser Health News, Rebecca Adams of CQ Roll Call, Alice Ollstein of Talking Points Memo and Margot Sanger-Katz of The New York Times.

Among the takeaways from this week’s podcast:

  • Kennedy’s retirement will put all eyes on the Senate, where Republicans have a slim majority but have also changed the rules to allow confirmation with only 51 votes instead of the usual 60.
  • The fight over Kennedy’s replacement is likely to galvanize both Republicans and Democrats, but also put in the hot seat the two Republican female senators who have supported abortion rights — Susan Collins of Maine and Lisa Murkowski of Alaska.
  • This week’s primaries again put the spotlight on Democratic support of single-payer health proposals, as Alexandria Ocasio-Cortez upset the fourth-ranking Democrat in the House in New York and former NAACP head Ben Jealous won the Democratic nomination for governor in Maryland. But while Democrats have made clear that health is their top issue for the coming campaign, they have so far managed to paper over their intraparty differences on incremental versus wholesale change.
  • The California legislature could vote on a measure as soon as Thursday that would gut efforts by municipalities to put in place soda taxes. If it passes, it will mark a change in momentum away from the success of these measures across the country. The soda industry took a page from the tobacco companies in executing this plan.
  • The controversy surrounding the Trump administration’s immigration policy that separates children from their parents at the border continued to be a flashpoint this week. Health and Human Services Secretary Alex Azar was questioned about it on Capitol Hill during a hearing about drug pricing. Congressional Republicans find themselves in a difficult position. Many don’t want to defend the administration, but there doesn’t seem to be an avenue by which to move forward either.