If I were a health care policymaker, I'd probably spend a whole lot more time than most of them do talking with real people who have real, "micro-world" questions which can illuminate the "macro-world" questions which the deep thinkers...well, think about.
Last week I spent a few hours over beers with a few friends who are pretty knowledgeable small business owners. Practical guys, with practical questions. The biggest one was this: Irrespective of the politics of Obamacare, what is the likelihood that some kind of regulatory or market force will actually bend the cost curve down?
Keep in mind that for most small business owners, annual premium increases of 15-25 percent per year have been the norm, not the exception. Even for fairly large small companies, premiums are doubling every five to six years.
I had to tell them the bad news: there's really nothing in the Affordable Care Act which has any concrete potential to reduce the rapidly-escalating price of health coverage, at least in the short to intermediate term.
That's because the Affordable Care Act essentially ignores the principal driver of health care cost increases: provider costs, especially on the hospital side.
Over eighty percent of health costs relate directly to payments to hospitals, physicians, drug and equipment companies, and other providers. And despite the potential promise of some of PPACA's experiments with delivery system reform, the likelihood is that those costs will continue to hyper-accelerate.
There is certainly a tempting target for cost containment: the estimated 210 billion dollars being spent on over-testing and over-treatment.
I wrote a little something about this phenomenon last year (http://polkiananalysis.blogspot.com/2011/10/economicsand-ethicsof-just-being-sure.html). And a recent column in The New York Times (http://well.blogs.nytimes.com/2012/08/27/overtreatment-is-taking-a-harmful-toll/?ref=health&wpisrc=nl_wonk ) expands on the theme.
Twenty to thirty percent of what we spend on health care can be retrospectively labelled as unnecessary. Let's pretend for a moment that, since one person's unnecessary treatment is another person's "do what it takes to help my Mom," only half that percentage is truly wasteful.
Would it/ should it be worth our time to figure out how to cut $100 billion or so per year out of our health expenditures? A reasonable person would say so.
But doctors get paid for how much they do. And while hospitals' primary business is treating disease, they are also in the business of maximizing revenue.
Unless there's a revolutionary (and counter-intuitive, for those revenue-conscious providers) trend toward awarding clinical efficacy versus the volume and intensity of services rendered, the cost curve isn't gonna bend appreciably over the next ten years or so. And until we can get to these root costs, we can expect to see health premiums double or triple over the same period.
What about defined contribution? Won't that have an effect on health costs?
A switch to a defined contribution will certainly do a lot to reduce small employers' cost exposure. But only by shifting the cost burden to employees, and making hyper-inflation their problem.
The myth of defined contribution is that employers will pass along a portion of the savings they experience by capping their own expenditures with their employees in the form of higher wages, which employees might use to pay for their share of health premiums. By and large, this won't happen.
The best example of why not is the proliferation of high-deductible health plans. The myth of HDHP's is that employers would establish partially-employer-funded Health Savings Accounts to enable their workers to cover their deductibles. Only about ten percent of small employers did this; the rest just saved the money.
And while defined contribution models are fine for large, self-insured employers...whose costs are lower to start with, and whose relationships with employees is largely...statistical...small employers tend to have personal relationships with their workers. Most (not all) understand that their employees are only a medical disaster from financial ruin. They see just unloading their problem on their workers not just as worrisome, but as an idea that can jump up and bite them, especially if their employees under-insure or, worse, take the employer contribution and pocket it.
Most small employers will not be subject to the mandate, but most suspect that, in the face of trouble, their employees, or their employees' lawyers, or, worse yet, the IRS, will be calling the business owner first.
My small business owner friends saw defined contribution as a short-term band-aid that simply sets the table for trouble down the road.
Won't health exchanges do something to reduce health costs?
I've written before that, properly organized and operated, health exchanges could do a lot to empower purchasers by aggregating demand and increasing purchasing power through effective administration and negotiation.
Haven't seen too many "active purchaser" exchange models yet. The Massachusetts Connector has certainly improved access for folks in that state, but hasn't had an appreciable effect on price increases.
And as of today, the vast majority of states have yet to begin seriously organizing their health exchanges; in fact, about 26 states have basically refused, for political and budgetary reasons, to consider getting into the exchange business. Most of these "hell, no, we won't go" states have Republican governors and legislatures.
It does strike me, a non-politician, as odd that these state leaders, proclaiming so loudly against federal interference in their health care systems, would default on the development of their own exchanges and create the scenario for a massive federal takeover of their health systems through the formation of a gigantic federal health exchange.
Maybe they're all expecting a Romney victory in November to make this issue go away.
But what if they guess wrong?
That's a damned fine question.
If they guess wrong, and President Obama is re-elected, I expect we'll see the Administration issuing waivers to states to give them more time to build their own exchange plans. So the "drop-dead date" for the formation of health exchanges will slip from January, 2014 to 2015 or later.
None of this should leave small business owners hopeful for long-term price relief any time soon. And yet, despite the confusion, the health insurance environment for small businesses hasn't really changed all that much. After all, if you've been swallowing 15-25 percent per year increases for the last 15 years, can it really get worse?
Tuesday, August 28, 2012
Wednesday, June 6, 2012
Will CO-OPs Bring A Sense Of "Community" Back To Health Care?
Okay, so...
The Supreme Court has upheld the constitutionality of PPACA. And the sun came up the next day.
I don't expect that the Court's decision changed anybody's mind about Obamacare. People who hated it still hate it, and are adjusting their political strategies accordingly. And those who hailed the law still like it.
But only in Washington does passing (or sustaining) a law mean the same thing as solving a problem. With the constitutionality of the law settled (for now, at least), the next focus should be on execution...implementation of some parts of the law that could have a positive impact on the availability of affordable health coverage in a more transparent and competitive market.
And one element of Obamacare which may have the potential to change a few markets is, in effect, an experiment to turn back the clock to a simpler (and vastly less expensive) time, when the health of a community was in the hands of community members themselves.
These experiments are called "Consumer Operated And Oriented Plans," or "co-ops."
Before there was employer-sponsored health coverage, before there were insurance companies, health care was often a community responsibility. The "communities" were church groups, ethnic organizations, or "benevolent societies," self-selecting communities through which members cared for one another. Everybody pitched in a little money, and if any member became ill, the "community" would assist the family in meeting medical expenses.
Those societies began to be replaced in the 1930's by Blue Cross and Blue Shield plans, larger, non-profit mutual insurance companies with Boards selected from among the members. These plans became the vehicles through which, especially after World War II, large employers began to provide health coverage to their workers, with the premiums covered as a substitute for wages, which were frozen for a time after the War.
Relatively few of these not-for-profit entities remain in the market today. The Cross and Shield plans began consolidating in the '90's into corporate giants. The Boards of a number of once-prominent non-profit health plans decided around the same time that their members' interests would be best served by being acquired by larger companies, the proceeds of the sale being used to set up foundations to maintain a sense of "community purpose."
Each step in the evolution of non-profit benevolent societies into corporate giants has moved health plans an additional step or two away from the interests of the member/customer/patient. With few exceptions, health plans are very large, very corporate, and their leaders are very dependent upon meeting the expectations of Wall Street, rather than of "Main Street."
That could begin to change...Maybe...
Thus far, 16 non-profit groups in 16 states have received nearly $1.25 billion in loans to establish non-profit health plans whose governing bodies will be selected from among their members, and whose surplus earnings (if there are any) will be re-invested in the development of improvements to the plans themselves, rather than distributed among stockholders. A complete list of the groups which have received funding is here: http://www.healthcare.gov/news/factsheets/2012/02/coops02212012a.html.
With the issue of PPACA's constitutionality settled, these groups should begin receiving funds to get themselves organized, and to achieve the killer deadline of bringing new, non-profit health plans into their markets by December, 2013, with coverage effective dates of January 1, 2014.
Most of these erstwhile co-ops have already announced their plans to offer plans in co-operation with their states' insurance exchanges...even in states which have yet to act to get into the exchange business.
The non-profits sponsoring these co-ops have considerable expertise, and some presence, in their states' health care and insurance markets, often as Medicare and Medicaid managed care plans. Some have a particular affinity for groups within their states, i.e., targeted markets to serve; the biggest winner is New York's Freelancers Union, which has won $340 million in loans to create plans for self-employed professionals in New York, New Jersey, and Oregon.
All of these groups have pledged to be "not just another insurance company." In many cases, that translates into pay for co-op leaders which is not "excessive." Other than that, plus the composition of their Boards (presumably volunteers), and their pledge to re-invest their surplus earnings, I'm hard-pressed to see what important differentiations will separate them from all those other insurance companies.
Co-ops must still enter into agreements with hospitals, physicians, and other providers, at some cost. Some co-ops are sponsored by existing managed care plans, which see branching out into the private market as a way to augment patient volume. Will those providers expect their privately-insured customers to be treated at about the same rates as their Medicare and Medicaid recipients, or will they expect a higher rate of payment, thus leading to the cost shifts typical of most provider networks?
How will they distribute and sell their products? Will they try to develop networks of agents, and pay them accordingly, or will they take the risk of experimenting with more cost-effective, technology-oriented marketing solutions?
While they may be technically non-profit, presumably the co-ops will still be subject to state premium taxes. They will have to maintain state-mandated reserves. The plans will need to comply with all coverage mandates required by their states.
My sense is that, whatever they may SAY, in real life, co-ops will need to operate very much like real insurance companies in order to compete and succeed in the marketplace. They're going to have to pay providers, sell products to customers, pay claims, and market themselves in states which are already dominated by huge competitors with very deep pockets. A very tall order.
The way for these groups to succeed will be 1) to get some sort of preferential pricing from providers (good luck), 2) keep their administrative ratios under 15%, 3) sell direct via the Web, and 4) use whatever short-term advantages they can produce to create enough critical mass (customers) to strengthen their hands in their continuing dealings with providers who want to get paid.
Co-ops will work best if their Boards see themselves as advocates for their members, and are in a position to negotiate in a constructive, but adversarial way with their providers. AND if their product and pricing mix is attractive enough that their markets view the co-ops as THEIR health plans, working for them. Part of that will be marketing, but a LOT will be execution, for the long term.
A famously aggressive Cleveland hospital CEO once responded to being cut out of a regional PPO network by starting up her health system's own health plan. To attract providers, the plan offered higher levels of reimbursement than the big PPO did. To attract distribution, the plan offered higher commissions. Employees of the health system were required to obtain coverage through the system's own health plan. At first, there was a lot of fanfare, including the CEO's own pronouncement that "any fool can run a health plan." The company soon went bust. Turns out the CEO was right: Any fool CAN run a health plan. But it takes a very special kind of fool to run a health plan right...and for the right reasons: to benefit the members collectively, for the long term...
The Supreme Court has upheld the constitutionality of PPACA. And the sun came up the next day.
I don't expect that the Court's decision changed anybody's mind about Obamacare. People who hated it still hate it, and are adjusting their political strategies accordingly. And those who hailed the law still like it.
But only in Washington does passing (or sustaining) a law mean the same thing as solving a problem. With the constitutionality of the law settled (for now, at least), the next focus should be on execution...implementation of some parts of the law that could have a positive impact on the availability of affordable health coverage in a more transparent and competitive market.
And one element of Obamacare which may have the potential to change a few markets is, in effect, an experiment to turn back the clock to a simpler (and vastly less expensive) time, when the health of a community was in the hands of community members themselves.
These experiments are called "Consumer Operated And Oriented Plans," or "co-ops."
Before there was employer-sponsored health coverage, before there were insurance companies, health care was often a community responsibility. The "communities" were church groups, ethnic organizations, or "benevolent societies," self-selecting communities through which members cared for one another. Everybody pitched in a little money, and if any member became ill, the "community" would assist the family in meeting medical expenses.
Those societies began to be replaced in the 1930's by Blue Cross and Blue Shield plans, larger, non-profit mutual insurance companies with Boards selected from among the members. These plans became the vehicles through which, especially after World War II, large employers began to provide health coverage to their workers, with the premiums covered as a substitute for wages, which were frozen for a time after the War.
Relatively few of these not-for-profit entities remain in the market today. The Cross and Shield plans began consolidating in the '90's into corporate giants. The Boards of a number of once-prominent non-profit health plans decided around the same time that their members' interests would be best served by being acquired by larger companies, the proceeds of the sale being used to set up foundations to maintain a sense of "community purpose."
Each step in the evolution of non-profit benevolent societies into corporate giants has moved health plans an additional step or two away from the interests of the member/customer/patient. With few exceptions, health plans are very large, very corporate, and their leaders are very dependent upon meeting the expectations of Wall Street, rather than of "Main Street."
That could begin to change...Maybe...
Thus far, 16 non-profit groups in 16 states have received nearly $1.25 billion in loans to establish non-profit health plans whose governing bodies will be selected from among their members, and whose surplus earnings (if there are any) will be re-invested in the development of improvements to the plans themselves, rather than distributed among stockholders. A complete list of the groups which have received funding is here: http://www.healthcare.gov/news/factsheets/2012/02/coops02212012a.html.
With the issue of PPACA's constitutionality settled, these groups should begin receiving funds to get themselves organized, and to achieve the killer deadline of bringing new, non-profit health plans into their markets by December, 2013, with coverage effective dates of January 1, 2014.
Most of these erstwhile co-ops have already announced their plans to offer plans in co-operation with their states' insurance exchanges...even in states which have yet to act to get into the exchange business.
The non-profits sponsoring these co-ops have considerable expertise, and some presence, in their states' health care and insurance markets, often as Medicare and Medicaid managed care plans. Some have a particular affinity for groups within their states, i.e., targeted markets to serve; the biggest winner is New York's Freelancers Union, which has won $340 million in loans to create plans for self-employed professionals in New York, New Jersey, and Oregon.
All of these groups have pledged to be "not just another insurance company." In many cases, that translates into pay for co-op leaders which is not "excessive." Other than that, plus the composition of their Boards (presumably volunteers), and their pledge to re-invest their surplus earnings, I'm hard-pressed to see what important differentiations will separate them from all those other insurance companies.
Co-ops must still enter into agreements with hospitals, physicians, and other providers, at some cost. Some co-ops are sponsored by existing managed care plans, which see branching out into the private market as a way to augment patient volume. Will those providers expect their privately-insured customers to be treated at about the same rates as their Medicare and Medicaid recipients, or will they expect a higher rate of payment, thus leading to the cost shifts typical of most provider networks?
How will they distribute and sell their products? Will they try to develop networks of agents, and pay them accordingly, or will they take the risk of experimenting with more cost-effective, technology-oriented marketing solutions?
While they may be technically non-profit, presumably the co-ops will still be subject to state premium taxes. They will have to maintain state-mandated reserves. The plans will need to comply with all coverage mandates required by their states.
My sense is that, whatever they may SAY, in real life, co-ops will need to operate very much like real insurance companies in order to compete and succeed in the marketplace. They're going to have to pay providers, sell products to customers, pay claims, and market themselves in states which are already dominated by huge competitors with very deep pockets. A very tall order.
The way for these groups to succeed will be 1) to get some sort of preferential pricing from providers (good luck), 2) keep their administrative ratios under 15%, 3) sell direct via the Web, and 4) use whatever short-term advantages they can produce to create enough critical mass (customers) to strengthen their hands in their continuing dealings with providers who want to get paid.
Co-ops will work best if their Boards see themselves as advocates for their members, and are in a position to negotiate in a constructive, but adversarial way with their providers. AND if their product and pricing mix is attractive enough that their markets view the co-ops as THEIR health plans, working for them. Part of that will be marketing, but a LOT will be execution, for the long term.
A famously aggressive Cleveland hospital CEO once responded to being cut out of a regional PPO network by starting up her health system's own health plan. To attract providers, the plan offered higher levels of reimbursement than the big PPO did. To attract distribution, the plan offered higher commissions. Employees of the health system were required to obtain coverage through the system's own health plan. At first, there was a lot of fanfare, including the CEO's own pronouncement that "any fool can run a health plan." The company soon went bust. Turns out the CEO was right: Any fool CAN run a health plan. But it takes a very special kind of fool to run a health plan right...and for the right reasons: to benefit the members collectively, for the long term...
Tuesday, May 1, 2012
"The Uninsured" Aren't "Them"...They're Us...
A report by the Commonwealth Fund should serve as a reminder that "the uninsured" are not a single population, but instead a diverse group of individuals who, for many different reasons, share one thing in common: for some period of time, they lack health coverage. And when that happens, they're often on their own...not in the "rugged individualist" or "free rider" context often suggested by their critics, but because they're essentially frozen out of the market by current "pre-PPACA" industry practices.
More information on the complete study is available here:http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Apr/Gaps-in-Health-Insurance.aspx
Commonwealth's study of over 2,300 individuals found that twenty-six percent of Americans went without health insurance for some period of time in 2011. And for the most part,those without coverage lost it because they'd lost their jobs.
Seven out of ten of those who lost their employment-based coverage were uninsured for more than a year. There are a number of reasons.
Because the continuation of coverage provisions under COBRA are mandatory only for companies with more than 20 workers (and often COBRA administrative services aren't available to groups with fewer than 20 employees), one reason for the coverage gap is that a continuation of employer-sponsored coverage isn't available to them at any price.
And even for COBRA-eligible employees, the cost of continuing coverage under COBRA, at the employer's cost plus two percent, makes it too expensive for families whose earning power has already been undermined by a layoff.
The individual market is no solution in most states. Individual policies tend to cost more, and cover less, than do group plans. And because most states still permit insurers to deny applicants for individual coverage due to health concerns, forty-five percent of those who applied for non-group coverage couldn't find any at an affordable cost.
For those who have the money, but are shut out of the market due to health, high-risk insurance pools can be a partial solution. Some states, and the federal government, operate plans to provide subsidized coverage for those with pre-existing conditions which make them ineligible for commercial coverage. The Federal government recently reported that over 50,000 Americans had enrolled in its temporary Pre-Existing Conditions Insurance Plan (PCIP) in its first 18 months of operations.
Participants in the PCIP rang up some $1.45 billion in health costs, largely for big-ticket items such as cancer and COPD. The plan's participants' costs averaged nearly $29,000 per person, and required a direct federal subsidy of some $600 million to augment what they'd paid in in premiums.
Looked at in another way, given that the current average per-employee cost of health coverage is about $13,000 per year, each participant in the PCIP requires at least one premium-paying adult to utilize nothing in order to create a subsidy for one PCIP participant.
In an earlier article (http://polkiananalysis.blogspot.com/2012/02/one-percent-most-of-us-are-headed-for.html), I pointed out that it takes six people paying premiums and using zero coverage to subsidize the costs on each member of the country's one percent of highest utilizers of health services. And it takes three healthy Americans to subsidize the costs of the next highest four percent of utilizers.
In "the olden days," health care coverage was sold on a "community-rated" basis, with an explicit understanding that those who didn't use a lot of health coverage would be paying a little more for their coverage so that those who really needed it could pay a little less.
The market has "evolved" to a point at which sharp dealers in the insurance business have convinced us that the insurance market is an "everyone for himself" market, in which we should pay for what our own coverage costs, with no sense of responsibility for the "community" in which we live and work. And, of course, many insurers have made a tidy buck by finding ways to avoid covering individuals whose needs would require more of a subsidy than their own premiums could cover. This sort of "precision..." dividing up the underwriting world into universes of one...has neither moderated health premiums for everyone nor made coverage more accessible to those who need it.
Instead we've created "ghettos" in which these "high-risk" individuals either receive crappy coverage at high costs, or are forced to do without.
And we demonize "the uninsured" as freeloaders who take advantage of "us..." a classic gambit of "blame the victim."
But increasingly, the uninsured aren't "them." They're us...our neighbors, our family members, our friends...and their families.
I can't speak for the big thinkers, but Ive had the experience of being without work, and of being expected to find $1800 a month for health coverage which my insurer initially offered me for $600 a month, till they found out I had a little high blood pressure and asthma.
It was agonizing to go without, but the monthly premiums were the equivalent of a monthly mortgage payment. We prayed every day that we'd remain healthy, and that our kids wouldn't break a leg playing soccer.
I didn't feel like a freeloader. I was terrified for my family. We were very close to the edge, and a single significant health problem would have driven us into the 40% of Americans whose bankruptcy filings are due to health care expenses. But our insurer's position was, "It costs what it costs. Take it or leave it."
We were lucky to find a job with employer-sponsored benefits eight months later.
I'll never forget that terrible time. But for most of The Deep Thinkers, with their comfy jobs and generous health benefits, that'll probably never be a worry. That makes it easier for them to think of the uninsured as "them."
Maybe a year or two without health coverage for all members of Congress would remind them that they're one of us.
More information on the complete study is available here:http://www.commonwealthfund.org/Publications/Issue-Briefs/2012/Apr/Gaps-in-Health-Insurance.aspx
Commonwealth's study of over 2,300 individuals found that twenty-six percent of Americans went without health insurance for some period of time in 2011. And for the most part,those without coverage lost it because they'd lost their jobs.
Seven out of ten of those who lost their employment-based coverage were uninsured for more than a year. There are a number of reasons.
Because the continuation of coverage provisions under COBRA are mandatory only for companies with more than 20 workers (and often COBRA administrative services aren't available to groups with fewer than 20 employees), one reason for the coverage gap is that a continuation of employer-sponsored coverage isn't available to them at any price.
And even for COBRA-eligible employees, the cost of continuing coverage under COBRA, at the employer's cost plus two percent, makes it too expensive for families whose earning power has already been undermined by a layoff.
The individual market is no solution in most states. Individual policies tend to cost more, and cover less, than do group plans. And because most states still permit insurers to deny applicants for individual coverage due to health concerns, forty-five percent of those who applied for non-group coverage couldn't find any at an affordable cost.
For those who have the money, but are shut out of the market due to health, high-risk insurance pools can be a partial solution. Some states, and the federal government, operate plans to provide subsidized coverage for those with pre-existing conditions which make them ineligible for commercial coverage. The Federal government recently reported that over 50,000 Americans had enrolled in its temporary Pre-Existing Conditions Insurance Plan (PCIP) in its first 18 months of operations.
Participants in the PCIP rang up some $1.45 billion in health costs, largely for big-ticket items such as cancer and COPD. The plan's participants' costs averaged nearly $29,000 per person, and required a direct federal subsidy of some $600 million to augment what they'd paid in in premiums.
Looked at in another way, given that the current average per-employee cost of health coverage is about $13,000 per year, each participant in the PCIP requires at least one premium-paying adult to utilize nothing in order to create a subsidy for one PCIP participant.
In an earlier article (http://polkiananalysis.blogspot.com/2012/02/one-percent-most-of-us-are-headed-for.html), I pointed out that it takes six people paying premiums and using zero coverage to subsidize the costs on each member of the country's one percent of highest utilizers of health services. And it takes three healthy Americans to subsidize the costs of the next highest four percent of utilizers.
In "the olden days," health care coverage was sold on a "community-rated" basis, with an explicit understanding that those who didn't use a lot of health coverage would be paying a little more for their coverage so that those who really needed it could pay a little less.
The market has "evolved" to a point at which sharp dealers in the insurance business have convinced us that the insurance market is an "everyone for himself" market, in which we should pay for what our own coverage costs, with no sense of responsibility for the "community" in which we live and work. And, of course, many insurers have made a tidy buck by finding ways to avoid covering individuals whose needs would require more of a subsidy than their own premiums could cover. This sort of "precision..." dividing up the underwriting world into universes of one...has neither moderated health premiums for everyone nor made coverage more accessible to those who need it.
Instead we've created "ghettos" in which these "high-risk" individuals either receive crappy coverage at high costs, or are forced to do without.
And we demonize "the uninsured" as freeloaders who take advantage of "us..." a classic gambit of "blame the victim."
But increasingly, the uninsured aren't "them." They're us...our neighbors, our family members, our friends...and their families.
I can't speak for the big thinkers, but Ive had the experience of being without work, and of being expected to find $1800 a month for health coverage which my insurer initially offered me for $600 a month, till they found out I had a little high blood pressure and asthma.
It was agonizing to go without, but the monthly premiums were the equivalent of a monthly mortgage payment. We prayed every day that we'd remain healthy, and that our kids wouldn't break a leg playing soccer.
I didn't feel like a freeloader. I was terrified for my family. We were very close to the edge, and a single significant health problem would have driven us into the 40% of Americans whose bankruptcy filings are due to health care expenses. But our insurer's position was, "It costs what it costs. Take it or leave it."
We were lucky to find a job with employer-sponsored benefits eight months later.
I'll never forget that terrible time. But for most of The Deep Thinkers, with their comfy jobs and generous health benefits, that'll probably never be a worry. That makes it easier for them to think of the uninsured as "them."
Maybe a year or two without health coverage for all members of Congress would remind them that they're one of us.
Tuesday, April 3, 2012
President Obama DARES Supreme Court To Throw Out PPACA...Who's Advising This Guy?...
I've long believed that if we held conversations only about what we knew, and not what we thought, those conversations would be a lot shorter.
So I was going to keep my big trap shut rather than join the chorus of talking heads and partisans of both persuasions about the possible outcome of the Supreme Court's review of PPACA's constitutionality.
But then The President goes and does something really, really dumb...
In remarks yesterday, President Obama declared that for the Justices to overturn PPACA on constitutional grounds would be a new high water mark for judicial activism. And that nine unelected judges shouldn't be permitted to overturn a law which had been enacted by a duly-elected Congress.
THEN he said that, since the linchpin of PPACA is the individual mandate, invalidating the mandate would essentially invalidate the law.
Set aside for a moment that, as my Mom would often comment, "What do you EXPECT the guy to say?". He is, after all, defending what he sees as the hallmark of his term.
But I'm astonished at the politically maladroit nature of his speech, and what those remarks imply about the nature and quality of the advice Obama is receiving from his handlers.
First, while the First Sports Fan is undoubtedly familiar with the term "a win is a win is a win," it's very clear to those of us at the grass roots that the passage of PPACA was a narrow partisan exercise. The law passed by one vote...hardly (you should pardon the expression)a mandate.
Second, there's growing evidence that, even though many Americans (seniors, dependent children and young adults, those with pre-existing health conditions whose coverage might otherwise be discontinued) have benefited significantly from the early enactment of provisions of the law, PPACA remains quite unpopular with voters. Perhaps because there hasn't been any REAL debate on the law's merits. The Administration has done a lousy job of making its case in the court of public opinion, instead banking on the smug position that once people understand how great the law is, they'll support it. I don't see that happening, do you?...At least not in the two years since its passage.
Then, to substance: Irrespective of whether the individual mandate was initially a trope of conservatives, it is just that: a trope, a commonly-stated idea which has been adopted as truth, despite there being little evidence to support it.
The mandate was a political tool, a sop to liberals who were seeking a "public option" for health coverage. Despite its being lionized on the left and vilified on the right, I've seen nothing from a credible third party which suggests that the economics of a mandate would lead to lower utilization of services or less cost-shifting from the uninsured to the insured. I've written about this before, here: http://polkiananalysis.blogspot.com/2011/01/what-difference-does-mandate-make.htmlt
My objection to the mandate has nothing to do with liberty. It's that the mandate will not achieve the economic goal it's been enacted to achieve, and that the enactment of the mandate will blow the lid off premiums, since the cost of coverage will no longer matter; the government says you have to have coverage, not that coverage needs to be affordable.
Finally, there's the issue of "severability." Virtually every piece of legislation incorporates a provision which states that parts of the law might be changed without invalidating the rest of the law.
What GENIUS in the Administration decided to leave severability language out of PPACA? I hope he or she is no longer employed. I'm sure it sounded like a swell idea at the time; "This way, if anybody decides to attack a component of the law they don't like, we can get right up in their faces and say, 'Oh yeah?...Well, just TRY to toss that provision out. You can't do that without throwing out the whole thing'."
And what GENIUS said, "That seems like a GREAT idea!"?
Even with all that, The President KNOWS the Supreme Court has essentially three options: they can maintain the entire law as constitutional; they can throw out the mandate and a couple related provisions and let the rest of the law stand; or they can toss the whole thing out.
Seems to me The President has DARED the Court to throw the whole law out the window, by making the political (not the economic) case that without the mandate the rest of the law can't stand.
And they might just accommodate him, and use his own words against him.
What do I THINK is going to happen? I think the Court will toss out the mandate, plus guaranteed issue and community rating, preserve those elements of the insurance reforms which have already taken effect (since, theoretically, the associated costs have already been baked into their rates, and say it's too early to make judgments on the rest of the law, since most of the provisions have yet to be enacted.
What do YOU think is going to happen, and what facts do you use to support your position?
So I was going to keep my big trap shut rather than join the chorus of talking heads and partisans of both persuasions about the possible outcome of the Supreme Court's review of PPACA's constitutionality.
But then The President goes and does something really, really dumb...
In remarks yesterday, President Obama declared that for the Justices to overturn PPACA on constitutional grounds would be a new high water mark for judicial activism. And that nine unelected judges shouldn't be permitted to overturn a law which had been enacted by a duly-elected Congress.
THEN he said that, since the linchpin of PPACA is the individual mandate, invalidating the mandate would essentially invalidate the law.
Set aside for a moment that, as my Mom would often comment, "What do you EXPECT the guy to say?". He is, after all, defending what he sees as the hallmark of his term.
But I'm astonished at the politically maladroit nature of his speech, and what those remarks imply about the nature and quality of the advice Obama is receiving from his handlers.
First, while the First Sports Fan is undoubtedly familiar with the term "a win is a win is a win," it's very clear to those of us at the grass roots that the passage of PPACA was a narrow partisan exercise. The law passed by one vote...hardly (you should pardon the expression)a mandate.
Second, there's growing evidence that, even though many Americans (seniors, dependent children and young adults, those with pre-existing health conditions whose coverage might otherwise be discontinued) have benefited significantly from the early enactment of provisions of the law, PPACA remains quite unpopular with voters. Perhaps because there hasn't been any REAL debate on the law's merits. The Administration has done a lousy job of making its case in the court of public opinion, instead banking on the smug position that once people understand how great the law is, they'll support it. I don't see that happening, do you?...At least not in the two years since its passage.
Then, to substance: Irrespective of whether the individual mandate was initially a trope of conservatives, it is just that: a trope, a commonly-stated idea which has been adopted as truth, despite there being little evidence to support it.
The mandate was a political tool, a sop to liberals who were seeking a "public option" for health coverage. Despite its being lionized on the left and vilified on the right, I've seen nothing from a credible third party which suggests that the economics of a mandate would lead to lower utilization of services or less cost-shifting from the uninsured to the insured. I've written about this before, here: http://polkiananalysis.blogspot.com/2011/01/what-difference-does-mandate-make.htmlt
My objection to the mandate has nothing to do with liberty. It's that the mandate will not achieve the economic goal it's been enacted to achieve, and that the enactment of the mandate will blow the lid off premiums, since the cost of coverage will no longer matter; the government says you have to have coverage, not that coverage needs to be affordable.
Finally, there's the issue of "severability." Virtually every piece of legislation incorporates a provision which states that parts of the law might be changed without invalidating the rest of the law.
What GENIUS in the Administration decided to leave severability language out of PPACA? I hope he or she is no longer employed. I'm sure it sounded like a swell idea at the time; "This way, if anybody decides to attack a component of the law they don't like, we can get right up in their faces and say, 'Oh yeah?...Well, just TRY to toss that provision out. You can't do that without throwing out the whole thing'."
And what GENIUS said, "That seems like a GREAT idea!"?
Even with all that, The President KNOWS the Supreme Court has essentially three options: they can maintain the entire law as constitutional; they can throw out the mandate and a couple related provisions and let the rest of the law stand; or they can toss the whole thing out.
Seems to me The President has DARED the Court to throw the whole law out the window, by making the political (not the economic) case that without the mandate the rest of the law can't stand.
And they might just accommodate him, and use his own words against him.
What do I THINK is going to happen? I think the Court will toss out the mandate, plus guaranteed issue and community rating, preserve those elements of the insurance reforms which have already taken effect (since, theoretically, the associated costs have already been baked into their rates, and say it's too early to make judgments on the rest of the law, since most of the provisions have yet to be enacted.
What do YOU think is going to happen, and what facts do you use to support your position?
Friday, February 3, 2012
The One Percent Most Of Us Are Headed For Eventually
A recent Federal study makes perfectly clear the massive subsidies baked into our public and private insurance systems resulting from an inescapable fact: demographics.
Most people know this stuff, but it's good to be reminded (I found it interesting, anyway).
The Agency For Healthcare Research And Quality got some headlines recently regarding its review of national health care expenditures distributed by demographic group (if you's like the whole thing, go here:http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.shtml). The major findings:
---In 2009, the top one percent of those utilizing health care services consumed nearly 22% of the value of health care services (20.2%) in 2008, for a mean expenditure of $90,061;
---In 2008 and 2009, the top five percent of utilizers consumed 49% of the value of services, with mean expenditures of $35,829;
---The top 10 percent of utilizers incurred 63.6% of costs in 2008, and;
---The bottom FIFTY PERCENT of utilizers incurred about THREE PERCENT of expenditures in the same period.
---The people most likely to be in the top ten percent are over 45, and covered by some form of public or private insurance. And once you're in, there's nearly a 50% chance you'll be a top ten percenter for a long time...nearly a 60% chance if you're a woman.
These findings are relatively consistent with research conducted annually since 2002. So the distribution is pretty constant. If you're interested in more detail and subtlety than I'm capable of here, you should look at the whole briefing.
The thing I find interesting is that the curve hasn't changed much for as long as I can remember.
And the data suggest that, for all the talk about consumer education and empowerment, incentives, wellness, whatever...No matter what we do, about ten percent of our population are going to consume over sixty percent of our health care dollars. Most of them will be older. And those old folks are going to be in the queue for a long time. AND those in the top ten percent are receiving a massive subsidy from the vast majority of health plan participants who are younger and healthier.
I don't use the term "subsidy" as conservative screed. It's a fact of demographics.
The old, sick folks who are receiving significant services today (and, really, at a mean expenditure of $90,000, the number IS significant, but not outrageous) were once, and for a long time, among the younger and healthier cohort. For a generation or more, they were the susidizers. Now they're the subsidized.
At a macro level, this all makes perfect sense. It's perfectly reflective of the notion of shared risk which is (or used to be, at least) the essence of group health coverage.
But I wonder what the implications are for the uninsured population (I think we're back to 47 million). About 6 million dependent kids got absorbed into the system thanks to SCHIP expansions and the new federal mandate on group health plans for kids under 26. About a third of the uninsured are uninsured for 60 days or less; they're in transition. Supposedly about a third are "young invincibles," who don't buy coverage because they consider it expensive or unnecessary.
But the remaining third are problematic. I suspect that a disproportionate share of the remaining population are people with enough health problems that they're either extremely expensive or impossible to insure. With a mean expenditure among the top 5% of users is $35,000, you probably don't need to be THAT sick to qualify for the top ten percent.
It will take more than 20 invincibles paying $350 per month in premiums, and using nothing, to subsidize one member of the top one percent. Even with a mandate, is there that big a group out there?...The numbers don't make sense to me.
Most people know this stuff, but it's good to be reminded (I found it interesting, anyway).
The Agency For Healthcare Research And Quality got some headlines recently regarding its review of national health care expenditures distributed by demographic group (if you's like the whole thing, go here:http://meps.ahrq.gov/mepsweb/data_files/publications/st354/stat354.shtml). The major findings:
---In 2009, the top one percent of those utilizing health care services consumed nearly 22% of the value of health care services (20.2%) in 2008, for a mean expenditure of $90,061;
---In 2008 and 2009, the top five percent of utilizers consumed 49% of the value of services, with mean expenditures of $35,829;
---The top 10 percent of utilizers incurred 63.6% of costs in 2008, and;
---The bottom FIFTY PERCENT of utilizers incurred about THREE PERCENT of expenditures in the same period.
---The people most likely to be in the top ten percent are over 45, and covered by some form of public or private insurance. And once you're in, there's nearly a 50% chance you'll be a top ten percenter for a long time...nearly a 60% chance if you're a woman.
These findings are relatively consistent with research conducted annually since 2002. So the distribution is pretty constant. If you're interested in more detail and subtlety than I'm capable of here, you should look at the whole briefing.
The thing I find interesting is that the curve hasn't changed much for as long as I can remember.
And the data suggest that, for all the talk about consumer education and empowerment, incentives, wellness, whatever...No matter what we do, about ten percent of our population are going to consume over sixty percent of our health care dollars. Most of them will be older. And those old folks are going to be in the queue for a long time. AND those in the top ten percent are receiving a massive subsidy from the vast majority of health plan participants who are younger and healthier.
I don't use the term "subsidy" as conservative screed. It's a fact of demographics.
The old, sick folks who are receiving significant services today (and, really, at a mean expenditure of $90,000, the number IS significant, but not outrageous) were once, and for a long time, among the younger and healthier cohort. For a generation or more, they were the susidizers. Now they're the subsidized.
At a macro level, this all makes perfect sense. It's perfectly reflective of the notion of shared risk which is (or used to be, at least) the essence of group health coverage.
But I wonder what the implications are for the uninsured population (I think we're back to 47 million). About 6 million dependent kids got absorbed into the system thanks to SCHIP expansions and the new federal mandate on group health plans for kids under 26. About a third of the uninsured are uninsured for 60 days or less; they're in transition. Supposedly about a third are "young invincibles," who don't buy coverage because they consider it expensive or unnecessary.
But the remaining third are problematic. I suspect that a disproportionate share of the remaining population are people with enough health problems that they're either extremely expensive or impossible to insure. With a mean expenditure among the top 5% of users is $35,000, you probably don't need to be THAT sick to qualify for the top ten percent.
It will take more than 20 invincibles paying $350 per month in premiums, and using nothing, to subsidize one member of the top one percent. Even with a mandate, is there that big a group out there?...The numbers don't make sense to me.
Thursday, December 8, 2011
Could Emerging "Private Exchanges" Foretell The End Of The Line For Brokers?
Entrepreneurship will almost always trump government regulation in this great country of ours. Somebody smart will almost always find a way to make a buck anticipating changes in government policy and practice. And if they're especially creative, they'll use the government's own policies as a jumping-off point.
While most insurers and agents are still sweating PPACA's mandate to create public health insurance exchanges in every state, a few private organizations are launching private efforts to create entities which THEY call "exchanges," but which may or may not embody the fundamentals of the exchange strategy laid out in PPACA.
A Minneapolis-based company, Bloom Health, scored major headlines in late September. Bloom has launched an "exchange"-type platform and process to administer defined-contribution benefits arrangements for employer groups. According to Bloom's propaganda,the company's pilot involved working with about 50 companies, with collective enrollment of about 25,000 employees. Employees were offered a variety of plan options, based on a fixed employer contribution, and given the chance to select one which made most financial sense to them. he Bloom system handled the enrollment and administration (not clear what happened at renewal time).
The process must have worked pretty well, since the company announced in late September that some 80% of its equity was being purchased by Wellpoint/Anthem, Blue Cross & Blue Shield of Michigan, and the holding company which owns the Texas Blues.
The acquiring companies will be tweaking the Bloom Health model, of course. They have no interest in a neutral marketplace. They intend to use the model to sell their own products in their own markets. So, as I understand it, in Michigan, the Bloom Health platform will be BCBSM's private fishing hole. Groups will be able to offer a variety of plan designs, but they'll all be offered by BCBSM.
In Western New York, Liazon has made a big splash with its Bright Choices benefits portal, through which companies with "1-2,500 employees (Liazon's propaganda)" can use a defined contribution strategy to "find a way out" of the problem of escalating employer health costs. Back in April, the company raised $12.5 million in capital to expand its marketing presence. Liazon has used Chambers of Commerce in New York and Maryland as vehicles to expand its reach. It would appear that the company's primary insurer is UnitedHealthcare, but they claim to offer coverage through a variety of other carriers as well. It's hard to find out how many companies have actually signed up, but the company's YouTube tutorials have experienced a couple hundred hits. My guess is that if enrollment was through the roof, we'd know about it.
And the consulting and brokerage giant Aon/Hewitt has made a big splash with its plans to launch a defined contribution "exchange" for giant employers which have agreed to use their proprietary platform to make a variety of Medicare Advantage plans available to retirees. Again, employers will provide retirees with a fixed monthly contribution, and retirees will be expected to select a Medicare Advantage plan from among those offered, and pay the difference between the employer contribution and the plans' costs themselves.
Here are some thoughts on these so-called "exchanges," just for the purpose of creative discussion:
1) One of the oft-expressed concerns of a lot of health care experts was that the development of exchanges under PPACA would lead to a mass exodus of small employers from the small group market. That may yet happen...but not for the reasons one might expect. These early pilots, driven by entrepreneurs who are interested in making a buck, suggest that smart people in the market are chasing self-insured employers, which are a) large, b) closer to their actual health care expenditures, since they pay them directly, and c) technologically sophisticated enough to roll out a defined contribution model quickly and efficiently.
2) The defined contribution model will certainly have the effect of enabling employers to control their health coverage expenditures...but will that's about the extent of their cost-containment ambitions. Just as was the case with the shift in pensions from defined benefit to defined contribution plans, these early experiments will demonstrate their efficiency at shifting downside financial risk from employers to individuals. There is some rhetoric which suggests that such a shift will create a new generation of "empowered" consumers, who will shop aggressively for cost-effective service providers. The rhetoric is mostly that. It is just as likely that large employers, having contained their own downside risk, will go about their businesses and leave their employees and retirees with hyper-inflating, undefined contributions in the face of hyper-inflating health care costs. I'm anxious to see evidence to the contrary...good luck finding any.
3) If there's any interesting benefit to be seen from these pilots, it will be in the havoc they wreak on the traditional distribution channels. Bloom and Liazon clearly have the potential to displace brokers from the health care coverage sales and service transaction, replacing them with technology and call center personnel. These companies are plainly seeking to disintermediate agents and brokers, and the costs they represent. Bloom claims that the company generates revenue from fees charged directly to employers. Liazon's revenue stream is a little less clear to outsiders, but even if the company generates revenues from sales commissions, I suspect the company can do quite well at a rate of compensation which is half, or less, of what insurers must pay their welter of retailers and wholesalers.
4) It's not clear how any of these pilots actually sell coverage. If I look at their processes, it seems they are based on the assumption that someone else has actually sold the product; their emphasis seems to be assisting employers in setting up their defined contribution plans, "educating" employees, and administering the allocation and collection of contributions on the back end.
5) This is what gives me pause about the implications of these pilots for small businesses. A potential downside of state exchanges for small employers and individuals (at least as they're conceived via PPACA) is that they will be,at best, passive tools available to those who seek them out. It seems to me that a private small group health exchange would have an advantage in its ability to market actively to small employers and self-employed individuals. Yet the focus of these pilots seems to be largely on administering post-sale transactions: enrollment, renewal, billing, collection and allocation of premiums from employers and employees.
Given that most insurers already have robust and powerful back-end applications to support large employers, the early focus of these experiments seems to be on how better to serve their largest and most profitable clients.
I stated in an earlier entry here (http://polkiananalysis.blogspot.com/2011/08/so-much-angstover-market-no-one-really.html) that, despite all the wailing and gnashing of teeth regarding emerging health exchanges, nobody seems to care too much about how the small group market is served. It seems to me that private small group exchanges will need to combine a mix of multiple carriers offering standardized plans on a common platform, aggressive marketing, good customer service, and a back end well-suited to bring the administration of both defined contribution and defined benefit plans down to groups of 50 or fewer employees. But with insurers, brokers, and consulting firms scrambling to find ways to serve their largest clients better, there's a strong possibility that the small group market will continue to be an afterthought, and that state exchanges will evolve quickly into a dumping ground for small groups and individuals.
If there are experimental models out there which can give me hope, I'd sure like to see them. If not, somebody's going to have to build one, or half the employees in our country will soon be even more dependent on the voluntary brilliance and largesse of insurance companies ever more reluctant to do business with them at all...which is, after all, how we got to this problem in the first place.
While most insurers and agents are still sweating PPACA's mandate to create public health insurance exchanges in every state, a few private organizations are launching private efforts to create entities which THEY call "exchanges," but which may or may not embody the fundamentals of the exchange strategy laid out in PPACA.
A Minneapolis-based company, Bloom Health, scored major headlines in late September. Bloom has launched an "exchange"-type platform and process to administer defined-contribution benefits arrangements for employer groups. According to Bloom's propaganda,the company's pilot involved working with about 50 companies, with collective enrollment of about 25,000 employees. Employees were offered a variety of plan options, based on a fixed employer contribution, and given the chance to select one which made most financial sense to them. he Bloom system handled the enrollment and administration (not clear what happened at renewal time).
The process must have worked pretty well, since the company announced in late September that some 80% of its equity was being purchased by Wellpoint/Anthem, Blue Cross & Blue Shield of Michigan, and the holding company which owns the Texas Blues.
The acquiring companies will be tweaking the Bloom Health model, of course. They have no interest in a neutral marketplace. They intend to use the model to sell their own products in their own markets. So, as I understand it, in Michigan, the Bloom Health platform will be BCBSM's private fishing hole. Groups will be able to offer a variety of plan designs, but they'll all be offered by BCBSM.
In Western New York, Liazon has made a big splash with its Bright Choices benefits portal, through which companies with "1-2,500 employees (Liazon's propaganda)" can use a defined contribution strategy to "find a way out" of the problem of escalating employer health costs. Back in April, the company raised $12.5 million in capital to expand its marketing presence. Liazon has used Chambers of Commerce in New York and Maryland as vehicles to expand its reach. It would appear that the company's primary insurer is UnitedHealthcare, but they claim to offer coverage through a variety of other carriers as well. It's hard to find out how many companies have actually signed up, but the company's YouTube tutorials have experienced a couple hundred hits. My guess is that if enrollment was through the roof, we'd know about it.
And the consulting and brokerage giant Aon/Hewitt has made a big splash with its plans to launch a defined contribution "exchange" for giant employers which have agreed to use their proprietary platform to make a variety of Medicare Advantage plans available to retirees. Again, employers will provide retirees with a fixed monthly contribution, and retirees will be expected to select a Medicare Advantage plan from among those offered, and pay the difference between the employer contribution and the plans' costs themselves.
Here are some thoughts on these so-called "exchanges," just for the purpose of creative discussion:
1) One of the oft-expressed concerns of a lot of health care experts was that the development of exchanges under PPACA would lead to a mass exodus of small employers from the small group market. That may yet happen...but not for the reasons one might expect. These early pilots, driven by entrepreneurs who are interested in making a buck, suggest that smart people in the market are chasing self-insured employers, which are a) large, b) closer to their actual health care expenditures, since they pay them directly, and c) technologically sophisticated enough to roll out a defined contribution model quickly and efficiently.
2) The defined contribution model will certainly have the effect of enabling employers to control their health coverage expenditures...but will that's about the extent of their cost-containment ambitions. Just as was the case with the shift in pensions from defined benefit to defined contribution plans, these early experiments will demonstrate their efficiency at shifting downside financial risk from employers to individuals. There is some rhetoric which suggests that such a shift will create a new generation of "empowered" consumers, who will shop aggressively for cost-effective service providers. The rhetoric is mostly that. It is just as likely that large employers, having contained their own downside risk, will go about their businesses and leave their employees and retirees with hyper-inflating, undefined contributions in the face of hyper-inflating health care costs. I'm anxious to see evidence to the contrary...good luck finding any.
3) If there's any interesting benefit to be seen from these pilots, it will be in the havoc they wreak on the traditional distribution channels. Bloom and Liazon clearly have the potential to displace brokers from the health care coverage sales and service transaction, replacing them with technology and call center personnel. These companies are plainly seeking to disintermediate agents and brokers, and the costs they represent. Bloom claims that the company generates revenue from fees charged directly to employers. Liazon's revenue stream is a little less clear to outsiders, but even if the company generates revenues from sales commissions, I suspect the company can do quite well at a rate of compensation which is half, or less, of what insurers must pay their welter of retailers and wholesalers.
4) It's not clear how any of these pilots actually sell coverage. If I look at their processes, it seems they are based on the assumption that someone else has actually sold the product; their emphasis seems to be assisting employers in setting up their defined contribution plans, "educating" employees, and administering the allocation and collection of contributions on the back end.
5) This is what gives me pause about the implications of these pilots for small businesses. A potential downside of state exchanges for small employers and individuals (at least as they're conceived via PPACA) is that they will be,at best, passive tools available to those who seek them out. It seems to me that a private small group health exchange would have an advantage in its ability to market actively to small employers and self-employed individuals. Yet the focus of these pilots seems to be largely on administering post-sale transactions: enrollment, renewal, billing, collection and allocation of premiums from employers and employees.
Given that most insurers already have robust and powerful back-end applications to support large employers, the early focus of these experiments seems to be on how better to serve their largest and most profitable clients.
I stated in an earlier entry here (http://polkiananalysis.blogspot.com/2011/08/so-much-angstover-market-no-one-really.html) that, despite all the wailing and gnashing of teeth regarding emerging health exchanges, nobody seems to care too much about how the small group market is served. It seems to me that private small group exchanges will need to combine a mix of multiple carriers offering standardized plans on a common platform, aggressive marketing, good customer service, and a back end well-suited to bring the administration of both defined contribution and defined benefit plans down to groups of 50 or fewer employees. But with insurers, brokers, and consulting firms scrambling to find ways to serve their largest clients better, there's a strong possibility that the small group market will continue to be an afterthought, and that state exchanges will evolve quickly into a dumping ground for small groups and individuals.
If there are experimental models out there which can give me hope, I'd sure like to see them. If not, somebody's going to have to build one, or half the employees in our country will soon be even more dependent on the voluntary brilliance and largesse of insurance companies ever more reluctant to do business with them at all...which is, after all, how we got to this problem in the first place.
Thursday, October 13, 2011
The Economics...And The Ethics...Of "Just Being Sure" And "Doing Something"...
The past few weeks have been a little intense for our family.
Our brilliant, beautiful, athletic 19-year-old daughter found a lump where there certainly shouldn't have been one and, naturally, promptly freaked out.
She's the scientific type, so we started with a little literature research, and found that for women her age, 99% of those lumps are nothing significant to worry about. But there's still that one percent.
So over four weeks, she went from her doctor to a specialist to a surgeon, and from X-ray to ultrasound to MRI. At every step along the way, she would be assured by the physician that the likelihood that the lump was anything to worry about was very small. Still, we went up the ladder of protocol. And after three physicians had seen her, and a radiologist reviewed all her tests, we found...nothing to be worried about.
So our daughter had a little scare...but no harm done.
Her EOB's for her various tests have just finished coming back. The assurance of "just making sure" set our health plan back about $10,000. I think we paid about $150 out of pocket.
It goes without saying in the health care racket that "unnecessary health care costs" are generally those incurred by the OTHER guy's daughter. Still, the episode left me thinking:
If we'd had no health insurance coverage, how far would our providers have gone "just to make sure?"
If we'd had a high-deductible health plan, with, say, a $6000 family deductible, how much would WE have been able to spend out of pocket, "just to be sure?" There's ample evidence indicating that subscribers to HDHP's tend to put off potentially costly medical procedures because of the out-of-pocket costs involved. Would we have just assured our daughter that "it's probably nothing," and urged her to be watchful in case there was any change?
It's cases like this which re-inforce to me the ludicrousness of the prevailing notion (among some circles) that "empowering individuals" is somehow the key to reducing health care costs. A scared 19-year-old kid with a mysterious lump is not inclined to be a discriminating shopper...even if there were reliable efficacy/cost/outcomes data out there...which, of course, there isn't.
And it also caused me to think about how many times a day similar scenarios play out. How many dollars are incurred on procedures which are initiated "just to be sure?" How many of these procedures are necessary? And how many cause more anxiety or lead to cascading medical interventions which make things worse?
Recent news contained a few answers which ought to give us pause:
Last week the U.S. Preventive Care Task Force, which raised a firestorm in 2009 when it questioned the efficacy of annual mammograms for healthy women, recommended that routine PSA screening should be restricted, especially for younger men with no signs or history of disease. A member of the panel said that, especially in younger men, “The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms," in the form of anxiety, unnecessary surgery, or other procedures;
Researchers at Mt. Sinai Medical Center in New York conducted a study which concluded that more than $6.7 billion in unnecessary tests and procedures were conducted at the primary care level last year, of which an astonishing 86% were attributable to the prescription of name-brand statin drugs to treat high cholesterol.
"Led by Minal Kale, MD, a postdoctoral fellow in the Division of Internal Medicine in the Department of Medicine at Mount Sinai School of Medicine, the research team reviewed findings from a study published in the May 2011 issue of Archives of Internal Medicine, which identified the top five most overused clinical activities in each of three primary care specialties: pediatrics, internal medicine, and family medicine. With this information, they performed a cross-sectional analysis of separate data that were pulled from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. They found more than $6.7 billion was spent in excess healthcare spending in the primary care setting in 2009. Eighty-six percent, or more than $5.8 billion of the unnecessary spending, resulted from the prescribing of brand-name statins rather than generic versions.
“Our analysis shows astronomical costs associated with prescribing of brand name statins when effective, generic alternatives were available. Efforts to encourage prescribing of generics clearly have not gone far enough,” said Dr. Kale. “Additionally, millions are spent on unnecessary blood work, scans, and antibiotic prescriptions. Significant efforts to reduce this spending are required in order to stem these exorbitant activities.”
And to raise the stakes further, an article in The Lancet rocked the establishment with a review of 1.8 million Medicare recipients over 65 who died in 2008. The study found that a third of those beneficiaries underwent surgery in the year before their death. One out of eight had had surgery in the month before their death, and one out of ten had undergone surgery in the week before their death.
While this makes sense on the surface...older people with health problems do undergo surgery, and many will die afterward...the study concluded that much of the surgery performed did not affect the patient's outcome.
More disturbingly, even physicians interviewed for the study suggested that the surgery wasn't necessary, but was instead performed to appease patients and their families, as an alternative to having "the discussion" about how the patient wished to spend what remained of his/her life. Surgeons, especially, often have the temptation to "do something" to help a patient, even if the procedure will have little or no clinical value.
And finally,The Agency For Health Care Research And Quality released numbers which indicated that treatment for septicemia, a blood infection featuring bacteria such as e coli and MRSA, was the single most expensive cost to U. S. hospitals in 2009, with a total cost of $15.4 billion. Septicemia cases, which are almost always the result of hospitalizations, increased from 337,000 in 2000 to 836,000 in 2009, making septicemia the sixth most common principal reason for hospitalization in 2009. Death rates from septicemia were also estimated at 16% in 2009...eight times higher than death rates from other causes...which demonstrates once again that, given rates of hospital-borne infections (always underreported by hospitals), hospitals are crummy places for sick people.
And besides, Medicare pays.
There are questions to be raised from these and all such studies; after all, when you don't agree with the outcome of a study, it pays to question the methodology. And all these studies admit variations in practice patterns (Medicare patients were three times as likely to have surgery in Muncie, Indiana than in Honolulu), but the facts remain:
Spending on tests and medical procedures, including surgery which, at the very least, do little clinical good and often can cause needless harm, add billions and billions and billions of dollars to American health care spending;
Among hospitals and physicians, especially as it relates to Medicare, there is a lot of conflicting pressure between clinical efficacy and the need to generate revenue;
Medicare is essentially a blank check;
Health plans aren't doing their jobs on behalf of their customers as a population;
And as the pressures on health expenditures rise, political and clinical leaders are going to have to confront the reality of "blank check" medicine. And because at least half of all health care expenditures are incurred by people in their last month of life, we're going to have to get over all this nonsense about "death panels" and begin an honest discussion of how we place limits on medical and surgical interventions at the end of life.
If cost containment were really a priority, these discussions would be happening now. But as long as hospitals, especially, are in the business of generating revenue from needless human suffering, those conversations are going to have to start somewhere else.
Our brilliant, beautiful, athletic 19-year-old daughter found a lump where there certainly shouldn't have been one and, naturally, promptly freaked out.
She's the scientific type, so we started with a little literature research, and found that for women her age, 99% of those lumps are nothing significant to worry about. But there's still that one percent.
So over four weeks, she went from her doctor to a specialist to a surgeon, and from X-ray to ultrasound to MRI. At every step along the way, she would be assured by the physician that the likelihood that the lump was anything to worry about was very small. Still, we went up the ladder of protocol. And after three physicians had seen her, and a radiologist reviewed all her tests, we found...nothing to be worried about.
So our daughter had a little scare...but no harm done.
Her EOB's for her various tests have just finished coming back. The assurance of "just making sure" set our health plan back about $10,000. I think we paid about $150 out of pocket.
It goes without saying in the health care racket that "unnecessary health care costs" are generally those incurred by the OTHER guy's daughter. Still, the episode left me thinking:
If we'd had no health insurance coverage, how far would our providers have gone "just to make sure?"
If we'd had a high-deductible health plan, with, say, a $6000 family deductible, how much would WE have been able to spend out of pocket, "just to be sure?" There's ample evidence indicating that subscribers to HDHP's tend to put off potentially costly medical procedures because of the out-of-pocket costs involved. Would we have just assured our daughter that "it's probably nothing," and urged her to be watchful in case there was any change?
It's cases like this which re-inforce to me the ludicrousness of the prevailing notion (among some circles) that "empowering individuals" is somehow the key to reducing health care costs. A scared 19-year-old kid with a mysterious lump is not inclined to be a discriminating shopper...even if there were reliable efficacy/cost/outcomes data out there...which, of course, there isn't.
And it also caused me to think about how many times a day similar scenarios play out. How many dollars are incurred on procedures which are initiated "just to be sure?" How many of these procedures are necessary? And how many cause more anxiety or lead to cascading medical interventions which make things worse?
Recent news contained a few answers which ought to give us pause:
Last week the U.S. Preventive Care Task Force, which raised a firestorm in 2009 when it questioned the efficacy of annual mammograms for healthy women, recommended that routine PSA screening should be restricted, especially for younger men with no signs or history of disease. A member of the panel said that, especially in younger men, “The harms studies showed that significant numbers of men — on the order of 20 to 30 percent — have very significant harms," in the form of anxiety, unnecessary surgery, or other procedures;
Researchers at Mt. Sinai Medical Center in New York conducted a study which concluded that more than $6.7 billion in unnecessary tests and procedures were conducted at the primary care level last year, of which an astonishing 86% were attributable to the prescription of name-brand statin drugs to treat high cholesterol.
"Led by Minal Kale, MD, a postdoctoral fellow in the Division of Internal Medicine in the Department of Medicine at Mount Sinai School of Medicine, the research team reviewed findings from a study published in the May 2011 issue of Archives of Internal Medicine, which identified the top five most overused clinical activities in each of three primary care specialties: pediatrics, internal medicine, and family medicine. With this information, they performed a cross-sectional analysis of separate data that were pulled from the National Ambulatory Medical Care Survey and the National Hospital Ambulatory Medical Care Survey. They found more than $6.7 billion was spent in excess healthcare spending in the primary care setting in 2009. Eighty-six percent, or more than $5.8 billion of the unnecessary spending, resulted from the prescribing of brand-name statins rather than generic versions.
“Our analysis shows astronomical costs associated with prescribing of brand name statins when effective, generic alternatives were available. Efforts to encourage prescribing of generics clearly have not gone far enough,” said Dr. Kale. “Additionally, millions are spent on unnecessary blood work, scans, and antibiotic prescriptions. Significant efforts to reduce this spending are required in order to stem these exorbitant activities.”
And to raise the stakes further, an article in The Lancet rocked the establishment with a review of 1.8 million Medicare recipients over 65 who died in 2008. The study found that a third of those beneficiaries underwent surgery in the year before their death. One out of eight had had surgery in the month before their death, and one out of ten had undergone surgery in the week before their death.
While this makes sense on the surface...older people with health problems do undergo surgery, and many will die afterward...the study concluded that much of the surgery performed did not affect the patient's outcome.
More disturbingly, even physicians interviewed for the study suggested that the surgery wasn't necessary, but was instead performed to appease patients and their families, as an alternative to having "the discussion" about how the patient wished to spend what remained of his/her life. Surgeons, especially, often have the temptation to "do something" to help a patient, even if the procedure will have little or no clinical value.
And finally,The Agency For Health Care Research And Quality released numbers which indicated that treatment for septicemia, a blood infection featuring bacteria such as e coli and MRSA, was the single most expensive cost to U. S. hospitals in 2009, with a total cost of $15.4 billion. Septicemia cases, which are almost always the result of hospitalizations, increased from 337,000 in 2000 to 836,000 in 2009, making septicemia the sixth most common principal reason for hospitalization in 2009. Death rates from septicemia were also estimated at 16% in 2009...eight times higher than death rates from other causes...which demonstrates once again that, given rates of hospital-borne infections (always underreported by hospitals), hospitals are crummy places for sick people.
And besides, Medicare pays.
There are questions to be raised from these and all such studies; after all, when you don't agree with the outcome of a study, it pays to question the methodology. And all these studies admit variations in practice patterns (Medicare patients were three times as likely to have surgery in Muncie, Indiana than in Honolulu), but the facts remain:
Spending on tests and medical procedures, including surgery which, at the very least, do little clinical good and often can cause needless harm, add billions and billions and billions of dollars to American health care spending;
Among hospitals and physicians, especially as it relates to Medicare, there is a lot of conflicting pressure between clinical efficacy and the need to generate revenue;
Medicare is essentially a blank check;
Health plans aren't doing their jobs on behalf of their customers as a population;
And as the pressures on health expenditures rise, political and clinical leaders are going to have to confront the reality of "blank check" medicine. And because at least half of all health care expenditures are incurred by people in their last month of life, we're going to have to get over all this nonsense about "death panels" and begin an honest discussion of how we place limits on medical and surgical interventions at the end of life.
If cost containment were really a priority, these discussions would be happening now. But as long as hospitals, especially, are in the business of generating revenue from needless human suffering, those conversations are going to have to start somewhere else.
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