Author: Ann Marie Marciarille

The transformation of the employer sponsored health care plans offered by Harvard University has hit the press. Heck, it was even discussed at AALS. Harvard has insulated its employees longer and more fully from the transformation — begun before the passage of the ACA but accelerated by its implementation — of its employer sponsored health insurance from a risk shifting to a risk sharing model. By this I mean that Harvard's employees are being introduced to a world of higher cost-share (deductibles, co-pays, etc.).  Some Harvard employees are not happy at all.

I am agnostic on the question of whether Harvard ought single-handedly bear the cost of expanded health insurance. Conversations about Harvard's endowment are inherently fraught.

Regrettably, what has gotten less attention is the idea that Harvard might — as some employers have — embrace narrow networks in at least some of  its offerings in order to offer a variety of plans that trade off choice and cost.  The New York Times did note: "But Harvard’s ability to create such networks is complicated by the fact that some of Boston’s best-known, most expensive hospitals are affiliated with Harvard Medical School. To create a network of high-value providers, Harvard would probably need to exclude some of its own teaching hospitals, or discourage their use."  

Oh, so much more could have been said.  Harvard's teaching hospitals are, in fact, a leading contributor to health care inflation in Massachusetts, as the Massachusetts Attorney General's 2013 report on the matter amply demonstrates.  The increased concentration of hospitals in Massachusetts, particularly those under the Harvard affiliated banner, has also played a significant role in high health care inflation in Massachusetts. And the proposed Partners Health merger, combining Harvard teaching hospitals with community hospitals has some people concerned that the post-merger entity will bring community hospitals under the Harvard teaching hospital reimbursement rate system.

If Drew Gilpin Faust were really serious about controlling health care costs for her employees, she might have to consider steering her own employees past Harvard affiliated facilities. But that may not pass the political laugh test.

Harvard may be learning what academic medical centers have been learning for a long time: it can be difficult to operate a medical center that serves your own employees at a cost effective price point, a bitter pill indeed.

X-posted at PrawfsBlawg.

 

 

I am, I concede, an odd television fan.  I probably spend more time reading about television than actually viewing it.  I actually enjoy reading reviews of television programs that I have no intention of ever viewing. Occasionally, however, a review or series of reviews makes me want to see something for myself.

And so it was with "The Knick", a bravura Steven Soderbergh creation (now with its second season in production) — a medical procedural set in a turn of the century New York City hospital. With almost its first scene a heartbreaking and gut wrenching failed cesarean section, whatever else The Knick represents, it is vivid. It is also somewhat clinically detached. Eventually we learn that the failed cesarian had been attempted unsuccessfully twelve times before by the same team. As one reviewer wrote, "The Knick uses historical distance to make sickness into something strange and unfamiliar, giving its doctors the aura of scientific adventurers." Adventurers they were. Later footage depicting brave experiments with unknown forms of anesthesia tip us off that the character of Dr. Thackery may, in fact, be based on extraordinary real-life surgeon Dr. William Halstead.  

It would be an understatement to describe Dr. Halstead as an adventurer. I do have to wonder if the series does him justice in one important regard. Noone comforts the crying (very soon to be dying) young cesarian candidate as she is wheeled into the operating theatre in "The Knick." It is apparent she senses she is near death but it is unacknowledged, although it is clear the risk is grave.

Dr. William Halstead, in fact, stood for a new gentler surgical approach, recognizing roughly handled tissues were often lost. No less than H.L. Mencken noted "[h]e showed that manhandled tissues, though they could not yell, could yet suffer and die."

The critics' reviews on "The Knick" are mixed. For each "Steven Soderbergh Made a Gilded-Age 'ER' and It's Riveting" review there is an equal and opposite "Surgical Strikeout."  "The Knick," it seems, suffers by comparison with  PBS's "Call the Midwife" (soon to be showing its fourth season with a fifth in production). "The Knick" is being criticized  for lack of character development when compared with the well-developed characters of both health care providers and patients in "Call the Midwife."

In all fairness, "Call the Midwife" has had far longer to develop the characters involved but these critics may have a point.  Patients in "The Knick" are often unnamed, breathtakingly mute or near-mute. Patients in "Call the Midwife" may even serve as recurring characters, as they did in Jennifer Worth's memoir on which the series, through season three, has been based.

Some of this is a difference in perspective. Jennifer Worth has left us her personal, professional, and spiritual autobiography in her three volume memoir of her time in East London.  Hers is a meditation on her personal transformation through service in a low income, low health literacy community. Over time, Jennifer Worth did not flinch to discuss the desperation of women with too many children and too little money. "Call the Midwife" is not for the faint of heart despite all those wonderful sepia colored images you may have seen of midwife Jenny Lee pedaling to a house call through the clotheslines of the East End tenements. The series itself is far grittier and Jennifer Worth's  memoir grittier still.

We will see where "The Knick" takes us.  Given that Dr. Halsted performed the first successful radical mastectomy for breast cancer in the United States, never mind transfused himself on the spot to save his sister's life post-partum, I can only imagine that more compelling drama is ahead. Oh, and did I mention he was a stickler for complete sterility in the surgical suite? I hope we get to see a more well-rounded presentation of this compelling, complex, and astonishing man.

And the mute young mother-to-be who never lived to grow into her role? She teaches us something as well about how the human touch, whether felt in carefully restrained surgery or attentive midwifery, can comfort and strengthen, even unto the last moments of life. 

 

X-posted at Prawfsblawg.

Just what is a perverse cross-subsidization? Is it seen only in the eye of the beholder?

The seemingly never-ending tussle over the clarification of the 340B drug discount program exemplifies how difficult it can be know just how, if at all, cross-subsidization works in our mixed up health care system.  The program, created in 1992, was designed to provide reduced acquisition cost pharmaceutical drug discounts to health care facilities disproportionately serving low-income patients.  

Now one third of our hospitals are enrolled, but we don't know if this is because of how we count the participants or because the value of acquiring expensive pharmaceuticals at the 340B acquistion cost and billing them out at commercial insurance rates was just too attractive to pass up.  Theories abound. You see, at present, the 340B subsidy does not have to flow to the commercial insurer, or Medicare, or anyone else — it is the facility's to dispense as it wishes.

Something is surely up. The number of health care facilities participating in the program has doubled from 2001 to 2011. And the OIG has taken an interest in the program's operation.

The American Hospital Association cites necessary subsidization of services to the poor and indigent, always a powerful claim in an entire health insurance system arguably built on cross-subsidizing care to the poor with higher charges to the commercially insured. One problem with this, however, is our failure to monitor this  cross-subsidization in any significant way. And, as Rena Conti points out, might the cross-subsidization not be seen as perverse if the 340B savings are not passed along to Medicare or the commercial insurer but, rather, retained by facilities that might not serve the poorest among us?

So much of this hinges on how we define "patient" in the 340B program and on how we want the program to work.  The 2014 failed Mega-Reg attempting to clarify patient definition — among other things — collapsed in the face of litigation.

What are hospitals and pharmaceutical companies really fighting over?  Money, of course, but also the very purpose of the program.  Is the 430B program supposed to provide the subsidy to the low income individual to improve access to expensive pharmaceuticals?  Or, is it supposed to provide a general subsidy to the operation of a safety-net hospital?  

 

A friend has written to ask me what Judge Winmill could have meant in the St. Luke's hospital-physician merger case when writing that the deal should be unwound because "there are other ways to achieve the same effect that do not run afoul of the antitrust laws and do not run such a risk of increased costs."

So, what are those things, my friend asks — joint ventures? Something else?

This is a great question. I, too, find Judge Winmill's assertion to be a little eliptical.  Other business associations and practice organization forms may offend antitrust law, short of a merger, so the technical form of the integrated entity can't be the problem (see Penn-Olin).  And it is always useful to argue that efficiencies that may be reaped short of a merger should be just that.

But I can't tell in the St. Luke's case whether Judge Winmill was more irked by bad economic analysis or the genuine failure of the combining parties to consider alternatives.  The cool thing is that a fair amount of the trial record has been made public in the St. Luke's matter, making it possible to know more than outsiders usually know about what happened in the presentation of the case. I need to read more.

Isn't it likely, my friend asks,  however the combined integrated entity is styled, that  referral exclusivity, as a practical matter, might spill over into some kind of de facto referral practice even outside of the ACO population?

This is a great question. It is sharpened by the special antitrust rules for analyzing Medicare Shared Savings Program participating entities. Those same MSSP rules are in the administrative rulemaking process even as we speak.  The proposed revised regulations  seem somewhat merger wary (p.55) and very concerned about ACO independence (pp. 57-66), just like my friend.

It has been an interesting month for those of us concerned about access to care for Medicaid beneficiaries.

First, the HHS Office of Inspector General relased a report surveying access to primary care providers and specialists in Medicaid  managed care.  Guess what? The plan directories were highly inaccurate as to basics such as provider name and location. Even when when accurate,  the directories listed many providers who were not accepting new Medicaid patients.  Even among those who could be located, were accepting Medicaid and indicated a willingness to accept new patients, five percent had appointments available only after a three month wait.

Second, the Urban Institute has issued a report discussing the likely Medicaid access implications of the scheduled termination of the ACA-generated Medicaid primary care fee bump on December 31, 2014. Interestingly, the fee bump appears poised to terminate on time even though most participating states were not able to implement until the second half of 2013. Although participants were eligible for retroactive bump payments, it is likely that uncertainty over the mechanics and duration of the bump helped to dampen participation.

What did we learn?  That is takes a long time for the bureaucracy to roll out a time-limited Medicaid fee bump. What we don't know is whether an increase in Medicaid primary care payment has produced an increase in primary care access for Medicaid beneficiaries or if any increase in the number of Medicaid participating physicians is national, regional, or local in scope.

Let's hope that the fifteen participating states that have announced their intention to continue the fee bump (using state funds) may actually keep it going long enough for us to learn something.  

Last month, the United States  Supreme Court declined to hear an appeal by Pharmacy Benefit Mangers ("PBMs") offended by California Civil Codes Section 2527's requirement that PBM's make bi-annual reports to pharmacies revealing PBMs' reimbursement rates for pharmaceuticals provided to uninsured customers. PBMs are the ultimate intermediaries between pharmacies and insurers, reimbursing pharmacies for submitted claims at networked rates unavailable to consumers without prescription drug benefits. They represent a highly concentrated powerful industry, one often under some form of ownership alliance with the largest pharmacy chains in the United States.

The battle over Cal. Civil Codes Section 2527 has been epic — with both the California Supreme Court and the 9th Circuit weighing in before the Supreme Court ended it last month.  Lots can and will be said about the first amendment implications of such mandated reporting. What interests me is how both sides wrap themselves in the mantle of protector of California's consumers. The PBM class members maintain that pricing secrecy allows them to drive ever lower networked rates and prevents those outside from using the now-to-be-disclosed information to shift costs to the network. The pharmacies claiming that pricing secrecy allows insurers to play games with the pharmaceutical pricing presented as black box inscrutable to the uninsured.

And which is it? Or, is it both? Like so many fair competition claims purporting to advance consumer welfare, might it be that not all consumers have the same interests?

Medi-Cal's great experiment in teledentistry is about to begin on January 1, 2015. Medicaid-funded dentistry in California is getting a group make over, courtesy of recent legislation expanding the types of procedures hygienists can perform without onsite supervison by a dentist, allowing remote consultation (hence teledentistry's name, based on the remote and not necessarily on-site consultation  and examination relationship allowed to be reimbursed).

Can't say I think "teledentistry" really captures it, though.  The dental services, in considerable part, will not be delivered remotely, just the collaboration.  Oh, and teledermatology is folded in there as well. There are lots and lots of other possibilities for removing the on site supervision scope of practice restrictions in health care if this California experiment goes well. 

Allison Hoffman has an interesting post on the November 14th Health Affairs Blog on the Risk and Reform of Long-Term Care, stemming from a presentation given at Yale Law School's recent conference on The Law of Medicare and Medicaid at Fifty.

I admire the post for its discussion of the cost to "next friends" or caregivers in our increasingly home and family based system of long term care.  Yes, what could only be described as a return to family based long term care is significant both for what it tells us about nursing home occupancy rates (trending flat or slightly down) and the work of assisting the increasingly long-lived in home and community based care (disproportionately the work of women in either setting).

Yes, Allison Hoffman makes the connection that when we are talking about family based long term care we are talking about female caregivers — those who pay the "hidden co-pay" of diminished life and retirement chances by providing these services.  But she fails to note that, when we talk about institutional long-term care, we are also talking about female caregivers — as nursing home and skilled nursing facility staff are overwhelmingly made up of female low wage workers — and also female residents.  You see, the odds of your ending up in a nursing home are much higher if you are female, not just because American women still outlive American men but because families are more likely to place Mom in institutionalized care.

"Hidden co-pay" — as marvelous as it is — may not do justice to the real story of the impact of family based and institutionally based long term care on women.   One of the  most common nursing home resident stories is one about the institutionalization of a former female caregiver, herself, after all. 

Now I have read the New York Time cover story on the trail of Ebola transmittal through one Liberian family twice.  Norimitsu Onishi has done something powerful here: weaving the individual stories of the members of the extended Dour-Doryan family in with a larger meditation on how care for the ill is delivered in poor family-based cultures. If your identity is in and through your family and you live in a place with a very modest health care infrastructure, home is — as Robert Frost famously observed— the place where,  when you have to go there, they have to take you in.

But, now, things are changing in Liberia. Ebola spreads quickly through families living in close quarters. But families are reluctant to deny care and physical comfort to family members. And so the blame game begins and families fracture over who brought the disease to the family and what must be done to drive it out. Interestingly, the families live in denial about Ebola's presence in the household while the neighbors always seem to see it clearly — until their household gets involved, of course.

If the account of five year old Esther Doryan's being driven, at the end of a stick, from the extended family household doesn't make you pause, the accompaning photograph of Esther lying by the side of the road will. (Esther appears dead but, picked up by clinic workers, lives a few more weeks in a treatment facility.)

Can we make home-based, family-based Ebola care safer for family caregivers? What can we learn from Fatu Kekula?

  

 

Who or what is One Medical Group and why do they write to me every week? Yes, I understand that I own residential property in a pretty spendy zip code, hence the endless direct mail urging me to pay what amounts to $150 a year in order to be able to get a same day or same week visit with a primary care provider using my existing health insurance.  Really? Even at my California  neighborhood's demographics this wouldn't make any sense unless One Medical Group also had some insight into how difficult it is to obtain a same day or same week appointment with Anthem Blue Cross in the East Bay. Now, that's niche marketing.

Visit One Medical Group's yelp page and you'll find happy yelpers extolling their magazine selection but also noting that — as the patient  panel has filled — same day and same week  appointments have grown scarcer.  In other words, interesting deal for those who joined when the ranks weren't full, less certain good value now.

Why does all this remind me of the selling of restaurant reservations?  Anything at all to cut the line, is it?   Or, is it that other people must be working the system to get their needs met now and anyone who gets told their needs are less urgent is either ignorant or without resources to test that proposition?

Oh, and my favorite Yelp post at One Medical Group is from the patient aghast that the nurse practitioner did not give her all five prescriptions she demanded for what may or may not have been  a sinus infection. Yeah, if you're paying that premium, apparently you even get to make the diagnosis.