Tag Archives: Medicare

Executive (Dis)order

The signing this morning of an executive order by the Orangutan will have, in the opinion of some of the bloggers and politicians, spell disaster for the nation’s health care system.

It will, if carried into action, likely siphon healthy people from the Affordable Care Act-compliant market, continuing a pattern of regulatory actions under the Trump administration that have undermined the ACA.

The rationale for such a move that has been given is that since Congress has not been able to repeal and replace the ACA, an executive order will, piece by piece.

Coupled with the recent budget move to eliminate the CHIP program for children’s health (New York State faces dire consequences if Congress does not act on CHIP), and cut backs to Medicare and Medicaid, the intent here is to privatize health care for some, and eliminate it for others, and to get government out of health care providing altogether.

There are provisions in this order for greater competition, short-term coverage, and lower premiums with less coverage. Why this is better is beyond me, unless the Orangutan is seeking to destroy health care so that single-payer will be the only option.

Cutting healthy people out of the ACA means leaving sick people to struggle with a health care law that many say needs to be fixed, not repealed and replaced. But because the Tea Party ranted and raved before it was enacted, and the Orangutan and the GOP campaigned on getting rid of it, they had no choice but to sabotage it if they could not do so through legislation.

I predict that we will soon see the total collapse of our health care system thanks to this stupid, overreaching, and ill-advised Executive Order. I even read today that the Vice President had to remind the Orangutan to sign the darn thing, something that almost slipped what is left of his so-called mind.

Welcome to Crackerbox Palace.

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“Yes, We Have No Humana”

Have you ever gone into a store looking to purchase an item they are supposed to carry because that is the kind of store they are, and been told that it is not available in your area?

For example, if I walked into a shoe store and wanted to buy a certain kind of very nice, but not too expensive shoe, and was told that shoe is not available in this area, I would feel that the act of buying shoes from a shoe store was somewhat disorganized and complicated. Especially if the store sells under their name (remember Florsheim?).

This is what happened to me today when I tried to get a Medicare Advantage plan for my medical condition from, you guessed it, Humana.

As my readers well know, I’ve been critical of Humana before due to issues with my late mother. However, after learning about Special Needs Plans from CMS, my agent informed me that Humana does not offer a Medicare Advantage plan for people with my condition in my area.

So, to use my shoe store analogy above, Humana does not sell Special Needs Plans (certain kind of nice, but not too expensive shoe) under their name in my area of the country.

How stupid is that?

Why shouldn’t everyone be able to buy the same shoe no matter where they live?

Naturally, if you wanted to buy sandals, and lived in Alaska during the winter, you wouldn’t, but all things being equal, you should.

Now I understand why in some counties there are only one exchange to purchase insurance, but again that is like saying there is only one shoe store in a certain county where you can buy shoes.

Totally wrong and bad for business. This is why we need Medicare for All, and should stop denying coverage to anyone, anywhere in the country, for whatever reason. If I buy that certain shoe in New York, I should be able to buy it also in California, Kansas, or anywhere else in the country.

To do anything less only makes the system worse.

So, “yes, we have no Humana, we have no Humana today.”

Another Scheme to Delay the Inevitable, part 2

Last week, I reported on an effort to create payer-provider partnerships, and said that it was another scheme to delay the inevitable move towards a Medicare for All, single-payer system.

Thanks again to Dr. Don McCanne for this week’s article from Modern Healthcare, on yet again another delaying tactic. This time it is from Congress, and while it purports to be “bipartisan”, it really isn’t, because they are very partisan in Congress today; partisan to the health care industry’s profit-making off of sick people.

Without further ado, here is the article in full:

http://www.modernhealthcare.com/article/20170803/NEWS/170809957

IT IS HIGH TIME TO STOP WASTING TIME, WASTING ENERGY AND THE PATIENCE OF THE AMERICAN PEOPLE WITH “SOLUTIONS” THAT ONLY MAKE THINGS WORSE, NOT BETTER. IT IS TIME TO EXPAND MEDICARE TO EVERYONE, WITH NO BUY-IN, AND BE DONE WITH IT.

 

 

Another Scheme to Delay the Inevitable

After my last post on my personal health issue and the debate over the health care bills that now have been shelved, I thought I’d share with you the following article in its entirety that is just another scheme to delay the inevitable fact that we will need and have a single-payer, Medicare for All health care system.

The article came to me courtesy of Don McCanne, former President of Physicians for a National Health Program (PNHP).

Here is the article:

Healthcare Dive
August 2, 2017
Health reform driving payer-provider partnerships
By Les Masterson
Payers and providers have for decades stayed in their silos, leading to a more fractured and adversarial healthcare system. That relationship, however, is starting to soften for many in the industry. Payer-provider partnerships put the two groups on the same team in hopes of reducing costs and improving care and outcomes through sharing data and better communication.
A major driver of these partnerships is the move away from fee-for-service payments and toward valued-based payments and population health management.
The payer-provider partnerships popping up across healthcare vary in type, size, location and model. There are 50/50 joint ventures with co-branding, and less intensive partnerships like accountable care organizations (ACO), patient-centered medical homes (PCMH), pay for performance and bundled payments.
The first step in these partnerships is building trust between payers and providers.
Another key is communication. (Chuck Lehn, president of Banner Health Network) acknowledged that communicating across systems and platforms between two organizations and healthcare providers requires time, attention and resources.
Caring for the whole patient works best when payers and providers share data, so there is improved care management, better interventions and better analytics around population health.
The two sides can go much deeper into care for patients by going beyond claims. In partnerships, payers shouldn’t have to wait for claims to see how their members are doing and doctors shouldn’t have to hope that their patients tell them when they have received care elsewhere.
In addition to regular back and forth, payers and providers need regular meetings, whether monthly or quarterly, that focus on strategic issues about the partnership, said (James Leatherwood, marketing communications manager at Availity).
One barrier that still needs resolution in partnerships is moving providers away from phone communication.
Leatherwood said a more efficient way is a queue system. In this system, a provider could check the status of all claims and get alerts when they need to provide more information. The system would allow providers to look in one queue, update the claims information and then move on with their day. Payers would have their own queue and would get alerts when providers have questions. This would reduce phone calls and create immediacy.
Leatherwood said the healthcare system is stuck in a “chart chase” between providers and payers, and moving to an automated queue system would be a gamechanger.
“I think in the near-term what we’re going to see is larger healthcare providers are going to be more strategic, working directly with payers. The health plans are going to be more interested not just in working with the staff level, but executive levels,” said Leatherwood.
The third part of a successful partnership is aligning incentives that focus on keeping people healthy and creating a positive healthcare experience, said (Thomas Robinson, partner at Oliver Wyman).
Partnerships must provide patients the right incentives, integration, investment, insight and innovation to work with the plan to deliver improvements across cost, quality, outcomes and experience, said Robinson.
“The point of these partnerships is to create something new, rather than just building the same old offerings with a narrow network. Successful partnerships will take the opportunity to innovate around the product and experience now that the incentives, insight, investment and integration are all for it,” said Robinson.
Aetna and Banner Health agreed on the partnership in October 2016 and have been laying out the groundwork before its launch this month in Maricopa and Pinal counties in Arizona. The two companies hope to expand the program statewide ultimately.
To prepare for the partnership, Tom Grote, who became CEO of Banner/Aetna joint venture in May, told Healthcare Dive that Banner Health and Aetna have developed joint operating committees, including marketing/sales and population health, that include members from both organizations.
The partnership looks to improve consumer experience by fully integrating providers, Aetna and administrative services, while eliminating redundancies in care and administrative problems. Aetna and Banner Health expect streamlining care and services will lead to savings for patients and employers.
(Brigitte Nettesheim, president of transformative markets for Aetna) said the partnerships are about “each side playing to its strengths, aligning incentives and driving scale.”
(Tom Leyden, director II of the Value Partnerships Program at BCBSM) said providers want to be active participants in system transformation.
“This requires ongoing support from the payer and demonstrated evidence of practice transformation and clinic results from the provider community,” said Leyden. “Administration of these programs is an integral aspect of measuring performance.”
Leyden said the payer strives to make the programs as manageable as possible because physicians need to perform many administrative tasks on an ongoing basis. BCBSM regularly solicits feedback from providers during quarterly meetings and phone calls, emails, webinars and in-person meetings on what’s working, what’s not and what needs to be changed.
“If we keep the customer — the end user — in mind and build partnerships with that as our North Star, we believe we will have a more successful, efficient and collaborative health system,” said Grote.
McCanne says they are the ones who control the medical industrial complex, and are part of the problem with our health care system. I agree.
And finally, here is a video from MSNBC with Ali Velshi debating a GOP’er on single-payer and Canada. The GOP’er says Canadians flock to the US for medical care, namely surgery, but Velshi disputes that rather forcefully.
Until we get these defenders of the status quo removed from Congress, we will never have the kind of health care all other developed nations have.
Health care is not a business, health care is a human right.

Now It’s Personal

Last week, some of my LinkedIn connections, as well as several other connections, learned of my recent hospitalization. The reason for this was not mentioned at the time, but I will tell you now.

Not having health insurance through an employer, and being denied renewal of a local county health care program, led to my going from Stage 4 to End Stage Kidney Disease.

The hospitalization last week was to place a catheter in me for peritoneal dialysis, and to repair an umbilical hernia.

My hospitalization was brought to light quite unexpectedly by my friend, Maria Todd. Maria’s sending best wishes for my speedy recovery and quick discharge from the hospital was much appreciated, and the warm words by others in response, and the thirty plus “likes” made me feel that people cared. For that. I am grateful.

But the events of the past month have brought home to me one very important point, given the current activity surrounding the so-called “repeal and replace” of the ACA, and the two Congressional bills that many consider doing more harm than good.

This nation needs Medicare for All.

There, I said it.

I know in the past, I have advocated single payer for others, but my illness has shown that anyone who loses health care for any amount of time, once they have reached adulthood, cannot go without health insurance.

This is what happens when men and women are removed prematurely from the workforce, for whatever reason, employer decides you are no longer wanted, economic downturn or just to eliminate positions that affect the bottom-line of the company, and are generally targeted to individuals in their 40’s, 50’s and early 60’s so that the company can save on health care costs for those employees, and so that younger workers can be hired to replace them.

This is not something new, and not related to automation and artificial intelligence disrupting whole industries, which is inevitable.

My initial view on single-payer was that if employers were no longer responsible for the health insurance of their employees, and they were guaranteed full coverage by the government, some of the job losses of the past decades would not have happened, and many talented men and women out of the workforce would be employed until their retirement.

If you don’t believe me, go to LinkedIn and read the many posts from such individuals who are still unemployed. One fellow in Texas even got turned down from jobs at fast food restaurants.

So, now it is personal for me.

I also know that many of you make your living from the health care system we currently have, and that some of you have expounded on why you think a single payer system is unrealistic.

I get it that your financial outlook depends on working in a broken, free-market system because it pays your salary, but healthcare was not supposed to be a business, nor was it supposed to marketed like any other commodity.

If you don’t believe me, read what Pope Francis said: “health is not a consumer good, but rather a universal right, and therefore access to health care services cannot be a privilege.”

But try telling that to Messrs. McConnell, Ryan, Paul, et al in Congress, and the current POTUS, all of whom want to eliminate medical coverage for millions of Americans they received under the ACA, cut back Medicare and Medicaid, and destroy Social Security.

Now that I will be receiving dialysis, and quite likely will qualify for disability, the prospect of not having those resources is very personal to me, and could literally mean my life.

Look in the mirror, then look at your spouse, your children, your parents, your neighbors, friends, etc. What do you think would happen to them if these programs were eliminated? Would you have enough money to care for them? Would you have money to pay for private insurance?

I lost my mother last month to dementia. She died on her 85th birthday in a nursing home some miles from my home (the home she and my father bought), but if the Republicans in Congress had gotten their way, and she had lived longer, I feared she would have been forced out of that nursing home, with no place to go, and would have been an even bigger burden to me.

So, I really don’t care if you are a Democrat, Republican, Independent, Libertarian, Socialist, Liberal, or Conservative, we all need health care at some point in our lives.

One of the friends I met here in Florida back in the 90’s died last July of a stroke. He was 73. He worked out, never smoked, had a good life, three kids, and like many of you, worked in Risk Management, as well as Human Resources, the legal profession, and served in Vietnam. But despite all that, he died prematurely, and went into involuntary retirement because he was in his 60’s. Luckily, his wife worked. But you get the picture.

We must all do our part to see that every American can get health care. Not just access to care, which is a Republican euphemism for being able to afford it, and if you can’t, too bad. But actual health insurance. Medicare for All.

Slight Increase in Average Medical Costs for Lost-Time Claims, Part 1

It’s that time of the year again, the time when I review the NCCI State of the Line Report.

As an added feature this year, I am including a look at the Medical Cost data, a new subject which I heard about back in February, when I attended NCCI’s 2017 Data Education Program.

First up is the distribution of medical costs by category. NCCI supports regulatory and legislative initiatives by providing State Medical Data Reports using data from their Medical Data Call.

For Service Year 2015, the distribution of payments across the various categories is based on data for all jurisdiction where NCCI provides ratemaking services, except Texas.

The key takeaway, as the following table will show, is that in 2015, physician costs were almost 40% (38%) of total medical costs, combined inpatient and outpatient hospital costs were approximately 30% (31%), and prescription drug costs were about 11%.

Table 1.

Table 1.

Source: NCCI’s State Medical Data Reports

Drilling down further, the distribution of physician costs for Service Year 2015, indicates that the bulk of the costs were associated with physical medicine, 30%, and surgery was associated with 24%, 10% associated with radiology, as shown in Table 2.

Table 2.

Table 2.

Source: NCI’s State Medical Data Reports

Getting even further, the next area the report covered was prescription drug payment changes over time.

The key takeaways here are the following:

  • In 2011, generic equivalents represented 47% of payments for all drugs prescribed. This increased to 58% by 2015, and driven largely by brand-name drugs.
  • Repackaged drugs now represent a small portion of overall drug payments because several states have implemented regulation on reimbursement.

Table 3.

Table 3.

Source: NCCI’s Medical Data Reports

NCCI analyzed the impact of prescription drug fee schedules on the cost of drugs by classifying states into one of four categories. States that had fee schedules were classified as Low, Medium, or High, based on the size of the Average Wholesale Price (AWP). The fourth category were states without a schedule.

The key takeaways here are:

  • Transitioning from not having a schedule to a low-fee schedule significantly reduces prices for WC prescriptions
  • Moving from no schedule to a high-fee schedule may increase drug costs, as shown in the following chart.

Chart 1.

Chart 1.

Source: NCCI’s Medical Data Reports

NCCI also looked at physician payments as a percentage of the Medicare reimbursement rate. In most states, they said, WC physician services are subject to fee schedules, just like the ones in group health and Medicare.

One way to measure physician costs across the states is to compare WC payments to the Medicare reimbursement rate.

The key takeaway from this is:

  • Prices paid relative to Medicare vary widely, from about 100% (Florida – 101%) to over 250%
  • Of the five jurisdictions with the largest percentage, all but Alaska (263%) are currently operating without a fee schedule
  • Countrywide the average is 150%

What does this mean for you?

While there are some positives in these numbers, especially with the cost savings from going to a low fee schedule for drugs, and an increase in the use of generic over brand-name drugs, and a decline in the percentage of repackaged drugs, medical costs are still very high for workers’ comp.

In the next post, I will look at the medical lost-time claim severity.

Disaster Averted

Yesterday’s crushing defeat of the so-called “American Health Care Act” or AHCA, signals the end of the seven-year long attempt by the Republican Party to legislatively kill the Affordable Care Act (ACA).

Yet, as was pointed out on one cable news network last night, it won’t stop the health insurance industry from getting the Republicans in Congress to kill parts of the law slowly by eliminating the taxes that go to pay for the coverage.

Call it “genocide by stealth”, since millions of Americans will die, as per the Congressional Budget Office (CBO’s) scoring of AHCA. If they can’t kill the law outright, the so-called “Freedom Caucus”, actually the Congressional version of the Tea Party, will kill it slowly.

Why do you think they keep saying it is a disaster and it is crumbling? It’s because they are dead set against anyone getting health care unless someone else can make a profit from selling a policy.

Then there is the other question, the one usually raised by liberals and progressives, especially those who supported Vermont Senator Bernie Sanders last year in the primaries, as to why we are the only Western country without universal coverage.

The answer is complex, but not complicated (“who knew health care was so complicated?). First, everything the government of the US has ever implemented for the benefit of people has had to pass muster with the Constitution. It either has to be covered by the Constitution directly, or implied through the taxing mechanism.

Second, the Founding Fathers never mentioned or promoted the right to health care, as the prevailing political and social philosophy of the day was concerned with freedom, liberty, and private property. It has been unclear what, if anything, was meant by the phrase, “life, liberty, and the pursuit of happiness”, let alone, the phrase, “promote the general welfare.”

Why they never mentioned health care and why other nations have it, is due to the fact that the US was founded during the first half of the period historians call, “the Enlightenment”, when the right to private property, liberty, and freedom were the topics of discussion on both sides of the Atlantic. Basically, the difference between Classical Liberalism (Conservatism) and Modern Liberalism (Liberalism) is between negative rights (the right not to be killed) versus positive rights (the right to a job, education, housing, health care, etc.)

Canada gained its limited independence from Britain nearly a hundred years after we did, and therefore was influenced by the philosophy of the second half of the Enlightenment, which stressed involvement by government in the economy.

The only time the Founders cared about providing some kind of health care plan was directed towards a particular group of citizens in the late eighteenth century, as I wrote about in this post.

What is now called the Public Health Service began as a government-sponsored, health plan for merchant sailors on ships entering and leaving US ports and on inland waterways. It was never challenged in the Supreme Court as unconstitutional, nor was it ever attacked by members of the opposition party. In fact, it was supported by both Federalists and Anti-Federalist politicians of the day.

The third reason why we don’t have universal, single-payer is because the government allowed employers to provide coverage during WWII to attract women into the workplace when the men went overseas. The UK is often cited as an example for single-payer, but what most supporters of this type of plan do not realize is that because of the devastation the UK suffered at the hands of German bombs, their health care system needed to be re-built from scratch, so the government stepped in with the NHS. Even Churchill supported it.

Fourth, we have always provided health care to certain at risk groups like the poor (Medicaid), the elderly (Medicare), and to children (CHIP), as well as to former service persons and their families (Tricare), etc. Perhaps the way to begin to get universal coverage is to merge all of these programs into one, then expand it to cover everyone else.

But for the time being, a major disaster was averted, but we should not think this is the end of the debate, nor is there victory. The battle lines are drawn, and the enemy is not surrendering. This is not a time for congratulation, but for vigilance and resolve.