Chief Justice Roberts reflects whether: “Did we spend all that time arguing about broccoli for nothing?”
Last week, I participated in a discussion of primary care provider supply on KCUR, Kansas City's local public radio affiliate. I was pleased to participate and enjoyed the conversation with my fellow panelist, Dr. Michael Munger and with our host Gina Kaufman. I suppose I was invited to participate because I just won't be quiet about primary care provider supply, medical school education, Kaiser Permanente's recent announcement of its decision to fix the broken pipeline of primary care providers representative of and responsive to communities with the greatest shortages by opening a proprietary medical school in southern California and on and on.
Today, I want to focus on a point made later in the radio program when listener call-in questions were fielded. One self-described "older" caller disparaged the rise of hospitalists and the use of hospitalists in places where they were previously unknown, including rural settings. Forgive me KCUR host Gina Kaufman, but the most interesting thing about the whole exchange with the call-in listener was that you did not seem to know who or what a hospitalist is until, apparently, you were guided to some understanding by someone in the studio. I note this without dismay for two reasons. First, unless and until you have experienced a hospitalization for something other than scheduled elective surgery or a planned normal birth, you may not have been introduced to the new normal: acute in-patient care delivered by a physician typically previously unknown to you, a provider often employed by the hospital itself, and a provider you are unlikely to ever encounter again outside of an acute care in-patient setting. Or, it could have been that the use of hospitalists in America's acute care in-patient facilities is so widespread that the term has become obsolete to lay people, though recognized inside baseball as the fastest growing medical specialty. Either way, the caller's point was that quality care should not be based on a system of strangers treating strangers. The easy answer to that is that electronic medical records will make us all strangers no more and that care by strangers is cost effective.
Whatever you make of the alleged impersonalism of modern health care, the caller may have been on to something in noting that there is an ongoing problem with the hand off between hospitalist provided hospital based acute care and the ongoing treatment and monitoring of things like chronic disease required of community based medicine. Our hand offs are problematic. Less expensive care in the in-patient acute care setting under the hospitalist combined with the costs of poorly integrated transitions to community based care on discharge can lead to higher community care based expenses along with the cost of unnecessary human suffering pushed elsewhere. So much of our health care system is financed and delivered under principles designed to push costs elsewhere in the system rather than acknowledge that poorly integrated care costs us all but costs some of us more than others.
So, whether you are in the "What's a hospitalist?" camp or the "You can see someone beside a hospitalist during an acute care admission?" camp, we all ought to be interested in valuing and prioritizing the hand off from acute in-patient care to community based care, where the real rubber meets the road.
X-posted at Prawfsblawg.
Peter Gosselin has an interesting post on exchange competition you can read here: http://about.bgov.com/2013-10-08/exchange-competition-cuts-health-insurance-costs-bgov-insight/. In it, he looks for some kind of connection between larger numbers of insurers operating in a federally facilitiated health insurance exchange and lower anticipated premiums. His focus is on rating areas with ten or more participating insurers, showing a 31 percent to 35 percent lower rate than those for the same policies in areas with only one issuer.
Now, some of this is old hat. There has been concern for some time that the ACA might simultaneously increase competition in markets that already have robust insurance market competition while simultaneously solidifying the virtual health insurance monopolies in some states. You can read an excellent two-part Kaiser Health News series on this here: http://www.kaiserhealthnews.org/stories/2013/april/23/stateline-lack-of-competition-hamper-health-exchanges.aspx
From this perspective, the remarkable thing would be to observe exchange-generated or exchange-enhanced health insurance market competition in states like Alaska, North Dakota, and Alabama.
Still, this is well done, so insightful that I have to wonder if it will be picked up by the general press where the focus tends not to be on the whole point of the ACA: to improve access while lowering costs and improving quality. Whatever the ACA's faults — and they are many — it deserves to be measured against its own goals.
Perhaps you are also struck by the irony of shutting down the federal government, in part, in an effort to derail the Affordable Care Act just at the time that the cannot-be-derailed opening of the ACA's health insurance exchanges is occurring. That said, pretending the exchange openings are derailed may be an interesting strategy. Perception is everything, or so they say.
In light of that, I take an interest in very early reports that New York's Exchange has crashed — overwhelmed by demand. Now, it is an open secret that CMS has been, sotto voce, advising advocacy groups to steer eager exchange enrollees away from all trying to access the system the minute it opens. Of course, the system was not designed for everyone to crowd in at once. Seen from one perspective, this is a failure of communication.
Seen from another, we have a little evidence that New Yorkers know a good deal when they see it and that scarcity can produce extreme reactions in the face of plenty (as scholars of obesity and public health can tell you at length).
Why the rush of the New York crowd to enroll in a New York minute?
First, New York has done extensive public outreach and education to publicize the exchanges, although counter-detailing has also been prominent. The press has also been vocal. You can see the Daily News' "how to" enrollment guide here: http://www.nydailynews.com/life-style/health/guide-obamacare-affordable-care-act-open-oct-1-article-1.1471102  And you can see the Heritage Foundation's Manahattan counter-advertising here: http://www.chicagotribune.com/news/columnists/ct-reu-usa–jpg-20130920,0,1248662.photo. Still, on the principle that all advertising is good advertising, anything that raises the profile of the ACA may serve, in part, to drive traffic to the New York exchange, though I am pretty certain whoever rationalized the cost of a billboard buy on 42nd street for counter-advertising had a different analysis.
Second, it is worth considering whether certain characteristics of the New York exchange have made it particularly attention-grabbing. To understand this, you need to know that for decades New York has had some of the highest individual market premiums. (Indeed, to understand much of the ACA, it is useful to understand the status quo ante of health insurance in the United States.) This is because, since 1993, New York has had a mandate for guaranteed issue without an individual mandate. A second important fact is that New York State requires full community rating, which means everyone buying the plan pays the same premium, regardless of age. This state option is quite unusual.
So, who is crashing the system in New York? My guess is that refugees from the individual market — particularly older refugees from the individual market. They have much to gain from New York exchange pricing under the individual mandate.
If I am even remotely correct, older New Yorkers under the age of 65 ( "non-elderly" to use insurance lingo where everyone over 65 is elderly) who have experienced scarcity by being priced out of the individual market are disproportionately crowding forward today. Now, the system needs younger enrollees to balance them out.
It is, in short, significant that the system may have crashed under the weight of the long-excluded seeking to enter the system but it is the full scope of enrollment (through March of 2014) that will tell us if all New Yorkers are onboard. This effort to achieve public buy-in is, from this perspective, a distance event and not a sprint.
Comparing the newly announced insurance rates between and even within states is difficult. Comparing the status quo ante with exchange rates fails to account for the richer health insurance benefits found in the ACA created health insurance exchanges. Comparing an urban state with a rural state fails to account for higher labor and overhead costs in the urban setting and the price effects of precious little health insurer competition in rural settings.
But I am intrigued by an article that examines the spread within a state or a major region, comparing the prices of higher cost (richer) health plans sold through the exchanges with more modest health plans (thinner) sold through the same exchanges. You can see a great article here: http://healthaffairs.org/blog/2013/08/07/premium-rate-variation-in-exchanges-is-an-eye-opener/
Why does this matter? It gives us a useful snapshot of how the structure of the exchanges has influenced beginning rates. It probably is too soon to tell if choosing to have an active purchaser exchange model is really what drives the relatively small spread between plan levels in California but time will tell, especially when we consider that (at least as of June 1, 2013) several other states had also chosen the active purchaser exchange model.
The federally facilitated exchanges (FFEs) are, of course, clearinghouse-style, offering none of the rate reduction that may flow from the state using its exchange organizing power to drive health insurance rates for products sold within it to lower levels by requiring a kind of bidding process for the privilege of selling within the exchange.
When I look at the prices of exchange purchased health insurance in the California exchange, I have to wonder if — when all is said and done — it may end up being more expensive to purchase through Missouri's FFE than to purchase through California's state-sponsored health insurance exchange.
My vote today is for the charming, if ever-so-slightly misleading (no rain!) "Long Live Oregonians" from Cover Oregon:
I go around telling people that information about ACA implementation ought to be as ubiquitous as those "Got Milk?" advertisements and that I would like to see some basic information on the side of milk cartons or on shrink wrapped cars tooling about Kansas City. I am still looking for some takers on those ideas, but in the meantime I am very taken with an ACA education pamphlet put out by some IOM members working with some Emory University students:
I like it because it includes some necessary health insurance vocabulary education in it as well. The ACA's health insurance exchanges would be far more approachable if the average American had a grasp on health insurance fundamentals. They do not. George Loewenstein, et al's forthcoming paper makes this very clear: http://www.sciencedirect.com/science/article/pii/S0167629613000532
But those of us who have spent ample time working with consumers, at almost all income and educational levels, knew this already.
Most sobering of all is the data on the limited number of Americans who understand fundamentals like health insurance co-pays and deductibles, essential to comparing plans both inside and outside the exchanges.
Here's the big takeaway: we were always ignorant and always paid the price for our ignorance. Now, we're going to be outed in our ignorance unless some serious thought is given to educating consumers about one of the single most important purchase decisions they will need to make for themselves and their families.
Leavitt Patners has produced a map showing ACO development intensity in various regions of the United States. You may see it here: http://medcitynews.com/2013/08/acos-by-the-numbers-where-are-we-now/
The map tells us a few things that make sense: as Medicare ACOs increase in numbers, ACOs participating in the MSSP or Pioneer ACO program have come to dominate the ACO landscape, ACO growth lags in rural areas, there is a multiplictiy of ACO models at play: smaller physician group initiated, large hospital centered, and multiple provider entity models.
Of course, with the exception of the small physician group centered model, these entities all have the advantage of size — both as to larger number of covered lives and number of providers. This may not be a bad thing, though increased provider concentration has been anything but a nostrum for health care inflation cost control to date, but they surely highlight the challenges of establishing a rural or semi-rural ACO.
Last week at SEALS, in a roundtable on ACOs, Professor Jessica Mantel (Univ. of Houston Law Center) mentioned the rural ACO gap. I have been thinking ever since about the realities of expecting rural would-be patients to travel some distance for health care. Would they travel or self-ration? Health care antitrust analysis teaches us that most patients — when considered from the perspective of acceptable travel times — are reluctant to travel far for health care, both for the time and expense involved as well as the not inconsiderable fear of being hospitalized far from loved ones. Would reasonable travel times for primary care have to be different from those for specialty care? All specialty care? In-patient care?
In a world where health care consumers are increasingly urged not to approach hospitalization alone, will travel for in-patient care promised as higher quality and lower cost appeal or not?
Well, it is official — now that the New York Times has taken note — that there will be considerable variation among and between the states' essential health benefits in the small and individual group markets under the ACA mandated insurance exchanges. You can see the NYT's announcement here: http://www.nytimes.com/2012/12/06/health/interest-groups-push-to-fill-margins-of-health-coverage.html?_r=0.
Of course, this continued flowering of health care federalism was foretold months ago in the announcement by the Secretary of HHS that, although the language of the ACA reserved the definition of EHB to the secretary, this definition would be developed in consultation with the states. This decision to allow, even under the ACA, for geography to be destiny in healthcare was a weighty one and one, I would imagine, brokered under pressure from all sides.
First, it is likely those states who had relatively rich state specific insurance mandates, pre-ACA, would not want to have equalized downward to a less rich essential benefit. This is why, I suspect, November 26, 2012's announcement of a a notice of proposed rule making on EHBs grandfathers in state-mandated benefits enacted before December 31, 2011 as part of EHB without additional costs to the states.
Second, it is likely those states who had relatively thin state specific insurance mandates, pre-ACA, would not want to have equalized upward to a richer version of essential benefits both as a cost savings matter and as a philisophical position on the wisdom of comprehensive health insurance. Let's call this the problem of moral hazard.
Where does this leave us? The tailoring of state-mandated benefits to fit with EHB combined with the EHB's benchmarking rules — essentially allowing a state to select a benchmark plan from between and among certain kinds of extant health plans offered within their state — goes a long way towards ossifying or codifying some of the gaps in coverage between and among states.
I discuss some of the implications of health care federalism and the ACA in my draft paper: Let Fifty Flowers Bloom: Health Care Federalism After National Federation of Business vs. Sebelius (forthcoming UMKC L. Rev. 2012), which you can also find posted here on SSRN:
if you care to read more.
On November 21st, CMS announced the three health care quality organizations chosen to be the first participants in a new ACA-created Medicare fee for service claims data transparency program. The Kansas City Quality Improvement Consortium is on the list. Surely this is one of those prizes where it is a prize to be chosen but also a significant challenge.
For the first time, the Medicare fee for service data set will be mined for provider-specific quality reports for access by someone other than the providers and CMS itself. The goal of the program is to improve provider performance by integrating information from the Medicare fee for service data set with information available from private insurers as well as public data to produce comprehensive reports on provider performance.
Given that provider specific performance data from the fee for service Medicare data set is the holy grail of individual provider assessment, KCQIC (and the two other organizations chosen) have their work cut out for them — responding to consumer clamor for more and more openly detailed data on provider quality on the one hand and responding to provider clamor for more and better systems for data privacy, security, and error correction on the other.
Why was KCQIC tapped? They've been threading this needle for several years already — in a more modest way — as grantees of the Robet Wood Johnson Foundation's Aligning Forces for Quality Project. Clearly, they relish a challenge.