Archive for the ‘health care’ Category

Quo Vadis, Kentucky?

Tuesday, July 10th, 2018

June 29, 2018. Thirteen days ago. I’m sitting in the Grand Ballroom of the Capital Hilton Hotel in Washington, DC, soaking in the presentations at the Annual Conference and CEO Summit of the Association for Community Affiliated Plans (ACAP). ACAP has grown to be quite the force for Medicare Advantage and Medicaid health plans around the country. So, the conference is an important event for Medicare and Medicaid professionals.

I’m looking forward to the 3:30 p.m. session, Plans Involvement in the New World of Work Requirements, because Mark Carter and Carl Felix, CEO and COO, respectively, of Kentucky’s Passport Health Plan, are going to describe their efforts to implement the Bluegrass State’s Medicaid work requirements.

In early January, 2018, Kentucky became the first state to win CMS approval to institute work requirements for its Medicaid beneficiaries. As I sit in the Hilton’s ballroom, its new  Medicaid work requirement program, Kentucky HEALTH, is slated to go live in two days (state government is only outdone by the US Army in its genius-like ability to create acronyms; this one stands for Helping to Engage and Achieve Long Term Health; catchy, eh?). There’s a pesky lawsuit lurking in the wings aimed at getting the Court to declare the program unconstitutional, but on June 29 Kentucky bureaucrats are ready to drop the hammer.

So, I am really interested in learning about the looming work requirement program, because three other states have won approval and are putting their programs together, and more are waiting in the wings.

Unfortunately, at the last minute, Mark and Carl (remember them?) have to cancel, because in the mad dash to the finish line for Kentucky HEALTH’s launch, they actually can’t leave the office. But, not to worry. Kentucky HEALTH’s Chief Marketing Officer is here to fill us in.

As she takes us through Kentucky HEALTH’s creation, I have to say that I, and the three or four hundred other people in the room are absolutely astonished at the time, money, manpower and all-around effort involved in giving birth to this behemoth. In terms of planning and implementation preparation, Kentucky HEALTH may perhaps only be exceeded by Operation Overlord (look it up). Some highlights:

  • For the first time EVER, Kentucky’s Medicaid beneficiaries will have to pay premiums. The premiums aren’t a lot (to you and me), ranging from $1 to $15 per month. Pregnant women and children are exempt.
  • Individuals with income above the poverty level ($12,060) who do not pay their premiums in 60 days will be kicked out of coverage for six months. Enrollees can return to the program earlier if they pay two months of missed premiums and make one new premium payment. They also must complete a financial or health literacy course.
  • Individuals must either work, volunteer, be enrolled in schooling or do some kind of “qualified community engagement” for at least 80 hours per month.
  • Beneficiaries must report their work activity each month; failure to do so will cause Medicaid disenrollment for six months.
  • Healthcare providers will have to certify to the Commonwealth the health status of those individuals they deem physically unable to work.

Regarding that last bullet – Kentucky HEALTH created a seven page form providers must complete. Knowing how busy healthcare providers are, I ask, “What’s been the feedback from your providers about this seven page form, and, by the way, are you paying them to do it?” Answer: “We haven’t communicated with the providers about this. We consider it all part of an office visit.”

For a moment, put aside why Kentucky is going to all this trouble. The bottom line question is: What does it get for going to all this trouble? In its need to get freeloaders off Medicaid rolls, just how many people would Kentucky’s work requirements actually put to work?

The nonprofit Kaiser Family Foundation provides some answers. Let’s check the numbers. Nationally:

  • About 10% of Medicaid recipients are elderly, age 65 and older, and many of them are in nursing homes.
  • About 48% are children, age 18 and younger.
  • That leaves about 42% who are of working age and potentially subject to the requirements.
  • Of that 42% who could be subject to the rules, 42% of them are already working full-time, and 18% are working part-time.
  • Another 14% are not working due to illness or disability.
  • Six percent are in school.
  • Twelve percent are caregivers for family members.
  • All of the above would be exempt from Kentucky’s rules.

That leaves about 1% of all Medicaid beneficiaries who would qualify for a work requirement program like Kentucky’s. That’s about 740,000 people nationally and around 12,000 in Kentucky (Since 2014, when Kentucky accepted Medicaid expansion, its Medicaid population has about doubled, rising from around 650,000 to 1.2 million) .

Kentucky HEALTH’s CMO wouldn’t (or couldn’t) say how much the state has spent on putting the program together or how many people have been devoted to it. But its best case scenario is that out of 1.2 million current beneficiaries about 95,000 may be off the rolls in five years, because either they no longer qualify for Medicaid because they either make too much money due to full-time work or they fail to comply with work requirements.

The day after the Kentucky HEALTH presentation at the ACAP conference District court Judge James Boasberg ruled Kentucky’s plan unlawful, because the federal government is obligated under federal law to consider whether a Medicaid proposal advances the program’s objectives, the judge wrote, and the Trump administration failed to meet that standard before approving Kentucky’s plan.

One final thought. When he announced the Trump administration’s approval of Kentucky’s work requirement plan, Governor Matt Bevin said, “I was raised by a father who said, ‘Don’t take something that is not earned.’” So, here’s the question: Unlike the entirety of the rest of the developed world, in America is basic health care something that has to be “earned?”

 

 

Bulletin: Dog Catches Bus! Now What?

Tuesday, June 12th, 2018

We’re goin’ right straight back to 2010
To start the health care war all over again!

It took time, but the GOP has finally learned a thing or two about fighting the Affordable Care Act, or, as they insist on calling it: Obamacare. You will recall that in 2017, after achieving control of all three branches of government, the party of Abraham Lincoln launched, in another Ground Hog Day moment, its biggest ever attack on the ACA, only to see its troops repulsed and annihilated once again by the turned down thumb of a war hero.

And then, after so many defeats there was a “light dawning over Marblehead” moment that would have made Prince Talleyrand proud.  In what the army calls a “triple flank,” republicans:

  1. In their humongously big 2017 tax cut law, zeroed out the penalty for not having health insurance;
  2. In February, 2018, got 20 states to sue the federal government contending that repeal of the penalty obviates the individual mandate making the entirety of the ACA unconstitutional.
  3. In May, 2018, somehow convinced the Justice Department not to defend the government in the suit.

Wow! A trifecta!

If the 20 states prevail, collateral damage abounds. First and foremost, the ACA’s provision that insurers not discriminate against people with pre-existing conditions. There are about 133 million Americans, under the age of 65, who fall into that health care Punji Pit. Prior to the ACA these family members, friends or neighbors of ours could be either denied coverage relating to their conditions, or charged exorbitant premiums. Beginning in 2014, the ACA forbade that. If the states win their suit, that meaty provision of the law, which a Kaiser tracking poll shows 70% of the population supports, gets torn up into little pieces and fed to the crows.

You might ask, “What do insurance companies think about all this?” Well, they do not like it one bit. America’s Health Insurance Plans, the trade association for health insurance companies, supports the pre-existing condition protections under the ACA. “Removing those provisions will result in renewed uncertainty in the individual market, create a patchwork of requirements in the states, cause rates to go even higher for older Americans and sicker patients, and make it challenging to introduce products and rates for 2019,” AHIP said in a statement.

So, here’s the question: If the 20 states actually win their suit, what happens then? Among many groups, the 1.25 million Americans with Type 1 diabetes who need to inject costly insulin every day to stay alive are waiting for an answer.

Health Wonk Review – Instagram Style

Thursday, May 17th, 2018

A picture’s worth a thousand words, and today Jason Shafrin proves it at Healthcare Economist. Jason has a photo, a chart, a graph and even a cartoon (for you Sponge Bob lovers) to illustrate what Health Wonk Review authors are posting.

We’re heading toward summer, although you’d never know it from the weather we’ve been gifted here in Massachusetts. Regardless, grab a mug of whatever you like, sit back, put your feet up and take a stroll through a Wonk garden filled with some excellent health care policy thinking.

It’s The Zip Code, Stupid! Update

Thursday, May 10th, 2018

At the end of February 2018, we wrote about a May 2017 study in JAMA Internal Medicine that concluded that where one lives is a bigger factor in health care outcomes than actual health care. This from our February post:

Geography is the biggest X-Factor in today’s American Hellzapoppin version of health care. The study analyzed every US county using data from deidentified death records from the National Center for Health Statistics (NCHS), and population counts from the US Census Bureau, NCHS, and the Human Mortality Databas and found striking differences in life expectancy. The gap between counties from lowest to highest life expectancy at birth was 20.1 years.

And, surpirse, surprise, it turns out if you live in a wealthy county with excellent access to high level health care, like Summit County, Colorado (life expectancy: 86.83), you’re likely to live about 15 years longer than if you live, say, in Humphries County, Mississippi, where life expectancy at birth is 71.9 years.  So, yes, Zip Code matters.

The concept of  zip code influence seems to be gaining traction. Today, from AIS Health Daily, we learn  a number of Blues Plans are planning on targeting the “where you live” problem with innovative strategies. Here is the AIS Daily release:

Blues Plans Work to Combat “ZIP Code Effect”
The Blue Cross and Blue Shield Association (BCBSA) recently launched the Blue Cross Blue Shield Institute, a subsidiary of BCBSA created to address social and environmental issues, as evidence mounts that health outcomes may be affected as much or more by social determinants of health as they are by actual medical care.
The Blue Cross Blue Shield Institute says it will address what it calls the “ZIP code effect,” which encompasses transportation, pharmacy, nutrition and fitness deserts in specific neighborhoods. It is partnering with Lyft, Inc., CVS Health Corp. and Walgreens Boots Alliance to address transportation and pharmacy deserts. The institute says it plans to deal with fitness and nutrition deserts in 2019.
Meanwhile, Highmark Inc. will launch a transportation initiative this summer to provide rides for members with chronic health conditions who live in a transportation desert. The service will begin in Pittsburgh as a pilot.
On April 17, Highmark’s Allegheny Health Network opened its Health Food Center, which acts as a “food pharmacy” where patients who lack access to food can receive nutritious food items, education on disease-specific diets and additional services for other social challenges they may face.
Other Blues plans also are addressing social determinants of health. For instance, Blue Cross and Blue Shield of North Carolina intends to invest part of its savings from the Tax Cuts and Jobs Act of 2017 into community health programs.
At Independence Blue Cross, the Independence Blue Cross Foundation’s Blue Safety Net Program offers “mobilized services” to medically underserved communities. The IBC Foundation sponsors the Philadelphia Eagles Youth Partnership’s Eagles Eye Mobile to conduct free vision screenings and eye exams and provide prescription glasses to under-insured and uninsured children.
We salute the Blues for recognizing the problem and trying to do something productive about it.
Final thought: If you do not subscribe to AIS Health Daily, you should.

This Can’t Go On Forever, Right?

Monday, April 23rd, 2018

The ratio of wages to the cost of living is what the economist calls real wages; the desirability of having real wages as high as possible, consistent with high employment, is a social objective. Rises in real wages do for the most part come about in fact as a consequence of rises in productivity. In a modern economy, what has [sic] normally to be expected  is rising productivity. – J. R. Hicks: Unions, Management and the Public; New York, Harcourt, Brace, and Co., 1960

What Hicks wrote 58 years ago had been true for more than 100 years. But 13 years later, in 1973, his economic model crashed. Productivity and real wage growth, which had been so tightly bound for so many years, parted company.

The consequences have been enormous. Hourly paid workers comprise about 60 percent of wage and salary workers. In Hicks’s day, nearly a third of all  workers were unionized. In 2017, however, the union membership rate had fallen to 10.7 percent, according to the U.S. Bureau of Labor Statistics. It’s only that high because of public sector participation. The union membership rate of public sector workers (34.4 percent) is more than five times higher than that of private sector workers (6.5 percent). Ponder that for just a moment. Only 6.5% of private sector workers are unionized today. This, despite union members having median weekly earnings about 25 percent higher than earnings for nonunion workers in comparable jobs ($1,041 versus $829).

This presents us with a befuddling paradox:

  1. Since 1973, the year when hourly wages and productivity waved goodbye to each other, real wages have been essentially flat, rising about 4% in the intervening 45 years;
  2. But in the same period, the CPI has risen 586%. That’s right. What you bought for $1.00 in 1973 will cost you $5.86 as of one month ago.
  3. Yet throughout this period, union participation and membership has declined by roughly 50%, despite union membership resulting in considerably higher wages for workers.

In Massachusetts, my home state, union membership was 12.4% in 2017, but 70% of that was in the public sector. At the recent Workers’ Compensation Research Institute’s annual conference I asked Steve Tolman, President of the Massachusetts AFL-CIO, why union membership hasn’t risen like a rocket to the moon given the persistent stagnant growth of real wages. He said he thought legislatures and employers had made it increasingly more difficult to win a union campaign. So, I then asked Keynote Speaker Erica Groshen, Ph.D., former Commissioner of the U.S. Bureau of Labor Statistics, her opinion. She wasn’t sure if there was a link between lack of union membership and stagnant real wage growth and suggested more research should be done. And in yesterday’s New York Times Louis Uchitelle suggested that American manufacturers relentlessly moving manufacturing jobs offshore has led to a steady decline in union membership – you can’t be in a union if you don’t have a job. The title of Uchitelle’s piece was, “How Labor’s Decline Hurt American Manufacturing.” Could have just as easily been titled, “How American Manufacturing’s Decline Hurt Labor.”

Regardless, what we’re left with is this (as I’ve written before): The 60% of the American workforce that is paid hourly resembles a swimmer trying to catch up to a battleship; with every stroke he falls farther and farther behind.

One highly illustrative area where meager wage growth has impacted the American family can be found in the cost of health care.

In 1989, Herb Stein (father of Ben), former Chairman of President Nixon’s Council of Economic Advisors, coined Stein’s Law*, which says, “If something cannot go on forever, it will stop.”

Do you think this can go on forever? What are the societal and political consequences if we see continued flat wage growth, the accelerating decline of private-sector unions, a rising CPI and an increasingly costly health care burden for families? Do you think today’s polarized American society is capable of addressing, let alone reversing, these decades old trends? What will it take for that to happen? I wish I knew.

But here is something I do know. If employers do not begin to do their best to address these issues – wage stagnation and ever rising health care costs that come with ever increasing deductibles – then unions and people like Steve Tolman, dormant for so long, will, and they’ll come with all guns blazing.

 

* Stein’s Law appeared on Page One of the June 1989 issue of the “AEI Economist” under the headline “Problems and Not-Problems of the American Economy.”

 

It’s The Zip Code, Stupid!

Monday, February 26th, 2018

“Sixty-percent of life expectancy, which has gone down two years in a row, is determined by where you live, 30% by your genetic code and 10% by the clinical care you get. Zip code matters more than genetic code.”

That was the sobering message delivered by AETNA CEO Mark Bertolini during an interview on CBS this morning. And he’s right. A May 2017 study from JAMA Internal Medicine concluded that geography is the biggest X-Factor in today’s American Hellzapoppin version of health care. The study analyzed every US county using data from deidentified death records from the National Center for Health Statistics (NCHS), and population counts from the US Census Bureau, NCHS, and the Human Mortality Databas and found striking differences in life expectancy. The gap between counties from lowest to highest life expectancy at birth was 20.1 years.

And, surpirse, surprise, it turns out if you live in a wealthy county with excellent access to high level health care, like Summit County, Colorado (life expectancy: 86.83), you’re likely to live about 15 years longer than if you live, say, in Humphries County, Mississippi, where life expectancy at birth is 71.9 years.  So, yes, Zip Code matters. According to the study:

In this population-based analysis, inequalities in life expectancy among counties are large and growing, and much of the variation in life expectancy can be explained by differences in socioeconomic and race/ethnicity factors, behavioral and metabolic risk factors, and health care factors.

On the whole, though, US life expectancy at birth increased by 5.3 years for both men and women — from 73.8 years to 79.1 years — between 1980 and 2014. But the county-by-county magnitude of the increase was determined by where one lives. That is, wealthy counties showed significantly greater increases in life expectancy than poor counties.

What is even more alarming is that some counties have experienced declines in life expectancy since 1980.

The JAMA study is another view from a different angle of inequality in America. According to Bertolini, CVS’s pending acquisition of AETNA, the third largest health insurer in the nation, will be a positive step in leveling the health care field when fully rolled out. He believes CVS’s 10,000 stores will evolve into much more than the Minute Clinics a lot of them are now. Time will tell, but CVS may be on to something here. In an op-ed in today’s New York Times, Ezekiel Emanuel pointed out that since 1981:

The population has increased by 40 percent, but hospitalizations have decreased by more than 10 percent. There is now a lower rate of hospitalizations than in 1946. As a result, the number of hospitals has declined to 5,534 this year from 6,933 in 1981.

People are apparently trying their mightiest to get health care anywhere except a hospital. According to Ezekiel, hospitals now seem less therapeutic; more life-threatening. Also, and this is where CVS is heading, complex care can now be provided somewhere else.

Another red flag from Mark Bertolini’s CBS interview was his reference to life expectancy dropping two years in a row. He’s right about that, too. In 2015 and 2016, life expectancy declined by a statistically significant 0.2 and 0.1 years, respectively.¹ Until now, life expectancy in America hadn’t declined since 1993.

All this is happening while our modern-day Tower of Babel – the US government – remains unwilling, unable, or both, to do anything constructive to improve the situation. Our more than 30-year health care train wreck needs serious attention, not partisan bloviation. To paraphrase Winston Churchill, ” That is a situation up with which we must no longer put.”

The men and women of Humphries County deserve nothing less.

 

¹ 2015’s drop was originally put at 0.1 year by the CDC, but was revised to 0.2 years after Medicare data were re-evaluated.

Going for the gold: An Olympic edition of Health Wonk Review

Friday, February 16th, 2018

Steve Anderson has posted the Health Wonk Review for February 15, 2018: Going for the Gold Edition at HealthInsurance.org blog. It’s an entertaining and wide-ranging smorgasbord of health policy topics of the day.

Here are a few of the topics d’jour:

  • Amazon/Bershire Hathaway/PMorgan’s foray into healthcare
  • Unexpected ER bills
  • CMS attack on freedom of the press
  • Predictions about Alex Azar, newly appointed HHS Secretary
  • The ACA
  • Peruvian healthcare
  • A different kind of hospital coverage
  • A recap of Health Action 2018, Families USA’s annual meet for healthcare activists.

If you aren’t familiar with healthinsurance.org, you should be. Check out the impressive roster of contributing authors and the excellent state health guides.

And just a heads up: In 2018, Health Wonks are on a once-per month schedule so catch this issue – you won’t have a chance for more wonkery until March.

Who’d A Thunk It? Something Good Out Of DC!

Monday, February 12th, 2018

Watching our legislators doing their thing in the nation’s capital, one can be forgiven for thinking Vlad the Impaler could learn a thing or two from these folks. But last Friday, in a rare Washington Kumbaya moment, peace broke out and the Bipartisan Budget Act zipped into law with the speed of an Olympic skater, Rand Paul notwithstanding.

The newly minted budget act has pork for everyone, but the pork I like is one little section that won’t get much press coverage, because it benefits poor people who are aging and sick: America’s Dual Eligibles. Duals are those among us who, by virtue of their age, health status and poverty are eligible for both Medicare and Medicaid benefits. The new budget act permanently re-authorizes Special Needs Plans aimed at caring for Duals.

Under the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) [Pub. L. 108-173), Congress created a new type of Medicare Advantage coordinated care plan focused on individuals with special needs. “Special needs individuals” were identified by Congress as: 1) institutionalized beneficiaries; 2) dually eligible; and/or 3) beneficiaries with severe or disabling chronic conditions. The MMA allowed for the creation of “Special Needs Plans” for these populations. For example, to accommodate the new legislation, my state, Massachusetts, created the Senior Care Option health plan, which “covers all of the services normally paid for through Medicare and MassHealth (Medicaid).”

Medicare, because of the aging of the Baby Boomers, and Medicaid, because of increasing poverty and state expansion through the Affordable Care Act, have grown significantly since 2010, making Special Needs Plans more and more important. Trouble was, Congress had to re-authorize the plans every few years. That concern is now in the past. The Bipartisan Budget Act, with its permanent re-authorization of Special Needs plans makes sure the safety net created by the plans is solid, secure and long-lasting.

The new budget act also re-authorizes the Children’s Health Insurance Plan (CHIP) for another ten years, something that has long had bipartisan support.

Finally, this Congress has done something that will benefit our most vulnerable citizens. Let’s hope it’s not a one-off.

Happy holiday Health Wonk Review

Thursday, December 14th, 2017

Santa reading Health Wonk Review

First, let us go on record for saying that there is no sly political motive to our use of the term “holiday” in the title of this post. Admittedly, we have a bit of a liberal slant, but we have no aversion to using the phrase “Merry Christmas.” But ho, ho, ho, we do have an inordinate fondness for alliteration. Of course, we might have called it the Happy Hanukkah Health Wonk Review instead, but we wanted to encompass Hanukkah, Christmas, Kwanza, New Year’s, and even the dubious Festivus. Whatever your flavor or inclination, we wish you a merry, happy, joyful one. Pentatonix says it better than we ever could, so a bit of a seasonal interlude before we get to this week’s entries.

The Happy Holiday Health Wonk Review

*** First up, at Managed Care Matters, Joe Paduda is never one to shy away from calling it as he sees it and this week his submission takes on the GOP tax bill, which he describes as “a mess, riddled with math errors, contradictory language, and un-implementable directives.” Congressional leaders say they have reached some agreement and will vote before the end of the year, so Joe’s post will give context.

*** Roy Poses proves once again that the devil is in the details and he consistently makes it his blogging business to dig through the details to hold feet to the fire. At Heath Care Renewal, he tracks down more about a barely-reported Pfizer settlement for “alleged” anti-competitive behavior that nearly slipped through the radar. He says that the lack of negative consequences suggests that the impunity of top health care leaders is is worsening. Check out his post One Barely Noticed Settlement by Pfizer Suggests the Futility of Polite Protests about Health Policy.

*** How will the CVS purchase of Aetna affect the healthcare landscape? Jason Shafrin aka The Healthcare Economist weighs in with his informed observations.  And another of our regular wonks weighs in on the merger. David Williams of Health Business Blog posts CVS + Aetna. Are we sure this adds up? Despite talksthat this combo will lead to a revolution in care delivery, he remains a skeptic and talks about why.

*** Acknowledging that the individual market for health insurance has become unaffordable for many of the unsubsidized — particularly older would-be enrollees — Andrew Sprung outlines various ways to keep Modified Adjusted Gross Income (MAGI) below the subsidy line. Check out his post Steering clear of the subsidy cliff in the ACA marketplace at xpostfactoid.

***  Vincent Grippi of CareCentrix submitted a fun #CareTalk video podcast, featuring HWR regular David Williams teaming with John Driscoll of CareCentrix. In a point-counterpoint format, they spar about the implications of 2017 elections on healthcare (think Maine), move on to value-based healthcare and they close the 10 minute segment with a lightning round.

*** Brad Flansbaum of The Hospital Leader has an interesting post about Locums vs F/T Hospitalists, posing the question, do temps stack up? He reports on a JAMA study, adding his perspective. Now I must confess that the term “locums” was a new to me, but Brad gives it good context. But if you are curious to the origins, as I was, Wikipedia is your friend.

*** In his post The Positive Side of Sharing, InsureBlog’s Henry Stern has the latest on a reader’s experience with a Health Care Sharing Ministry. (He offers this spoiler alert: it’s actually been pretty good).

*** Shopping for individual health insurance or know someone who is? If your state uses HealthCare.gov, you have until December 15 to enroll, but in other states, you may be able to enroll as late as January 31. Victims of Hurricanes Irma and Harvey may also have extensions. Louise Norris has all the details in her  guide to buying individual health insurance at healthinsurance.org. For more, see Timothy Jost’s post on Health Affairs Blog: Open Enrollment Ends Friday—Except For Those Qualifying For Special Enrollment Periods.

*** For our post, we’re delving into our archives for an expose of a mysterious employer. Many have nothing but good to say about him, but others think he is not a good employer. Judge for yourself:

Santa’s workshop: “OSHA problems galore” say whistleblowers
The risks of being Santa
Is Santa Claus a bad employer?

 

Health Wonk Review’s “Pink Edition”

Thursday, October 12th, 2017

InsureBlog’s Hank Stern has posted the latest edition, the “Pink Edition,” of Health Wonk Review.

Why the “Pink Edition?” Because October is National Breast Cancer Awareness Month, and Hank and his team, Love, Hope and Faith, are doing their best to raise money to help eradicate this terrible disease. They’re participating in a walk to do just that on October 21, and Hank would love some help from the HWR community. Something to think about.

So, after making a donation to Hank’s worthwhile cause, we hope you’ll grab a cup of whatever suits you best, put your feet up and once again revel in all things health wonkery.