September 26, 2015
Replacing the "hated" Sustainable Growth Rate Formula
(SGR) in April of this year ended some deep flaws in the Medicare
payment system for physicians, but other concerns remain, according to
two papers published in the September 24 issue of the New England
Journal of Medicine.
September 23, 2015
Mr. President, I am deeply grateful for your welcome in the name of all Americans. As the son of an immigrant family, I am happy to be a guest in this country, which was largely built by such families. I look forward to these days of encounter and dialogue, in which I hope to listen to, and share, many of the hopes and dreams of the American people.
Mr. President, together with their fellow citizens, American Catholics are committed to building a society which is truly tolerant and inclusive, to safeguarding the rights of individuals and communities, and to rejecting every form of unjust discrimination. With countless other people of good will, they are likewise concerned that efforts to build a just and wisely ordered society respect their deepest concerns and their right to religious liberty. That freedom remains one of America's most precious possessions. And, as my brothers, the United States Bishops, have reminded us, all are called to be vigilant, precisely as good citizens, to preserve and defend that freedom from everything that would threaten or compromise it.
The efforts which were recently made to mend broken relationships and to open new doors to cooperation within our human family represent positive steps along the path of reconciliation, justice and freedom. I would like all men and women of good will in this great nation to support the efforts of the international community to protect the vulnerable in our world and to stimulate integral and inclusive models of development, so that our brothers and sisters everywhere may know the blessings of peace and prosperity which God wills for all his children.
Proposed mega-mergers between health insurance giants prompted by the Affordable Care Act won't harm the level of competition in the market, two chief executives pledged this week to skeptical lawmakers from both parties. The recent plans by Aetna Inc. to acquire Humana Inc., and by Anthem Inc. to buy Cigna Corp., have raised concerns over the economic impact that such mergers, which would eliminate two of the five largest insurers to create three companies, would have on consumers. The Justice Department is investigating the deals.
In their attempt to convince
senators of the mergers' virtues, the CEOs of Aetna and Anthem each
said healthcare should be viewed within a local context and that the
mergers would lead to robust competition without raising prices for
He recalled Aetna's
billion-dollar acquisition of Prudential Health Care in 1999. Leemore
Dafny, a professor at Northwestern's business school, testified that
the deal cut both jobs and wages in the
locations where the two companies overlapped, as well as reduced
payments to health care providers.
Senators from both parties
raised concerns about how the deals would affect healthcare costs.
According to a new survey, American workers saw their out-of-pocket
medical costs jump again this year, as the average deductible for an
employer-provided health plan grew nearly 9% to more than $1,000.
Furthermore, with Anthem's
affiliation with the extensive Blue Cross and Blue Shield system, a
merger with Cigna, he said, could all but eliminate competition and
entrench the system's domination in nearly every state.
Sen. Mike Lee (R-Utah),
chairman of the Judiciary antitrust subcommittee, said Tuesday's
hearing was not about President Obama's landmark 2010 healthcare law.
Jeanne's Comment: Yeah, like we should trust these CEOs ... like we "trusted" the tobacco industry CEOs who said cigarette smoking wasn't addictive or harmful ... or the auto execs who told us their cars were safe and didn't have acceleration or breaking problems and that their cars didn't pollute ... or the banking CEOs who told us that their sub-prime mortgage manipulations were all fine and dandy ... or coal industry CEOs ... or the industrial farming execs ...and the list goes on ...
September 22, 2015
Democrats facing tough elections have been running away from Obamacare in their campaigns almost since the law was passed (and paid dearly for this mistake by losing big in off year presidential elections), but Hillary Rodham Clinton is taking a different approach for 2016. She is embracing it. On the campaign trail, Clinton is leaning into the Affordable Care Act, touting the health insurance mandate as a signature achievement of Democrats as the law -- about which the public remains deeply divided -- has become firmly embedded in the nation's healthcare system and is delivering sweeping new benefits to millions of voters.
This week Clinton unveiled a plan to expand the law's
reach with a proposal to force down the prices of prescription drugs.
She will call for new federal rules to cap what consumers are forced
to pay out of pocket for medicines, and she would allow the federal
government to negotiate directly with drug makers to secure lower drug
costs for seniors on Medicare.
The plan would allow Americans to buy prescription
drugs abroad, where prices are often lower; prohibit drug companies
from writing off the cost of advertising; and limit profits the
companies can make from drugs developed with the help of federal
research subsidies. It would also boost spending at the Food and
Drug Administration so prescription drugs could be approved for sale
more quickly. Prescription drugs account for just 10% of the nation's
healthcare spending, but rising prices and the proliferation of
headline-grabbing specialty medications that cost tens of thousands of
dollars, such as the hepatitis C drug Sovaldi, are driving public
Clinton was particularly critical of Republican
governors who spurned federal dollars to expand their Medicaid
programs, a key provision of Obamacare. In Baton Rouge, she called out
by name Gov. Bobby Jindal, himself a presidential candidate, for
refusing the subsidies, charging that it left 190,000 people in the
state without insurance. Jindal responded by challenging Clinton to a
debate on the issue.
Clinton chose Arkansas and Louisiana on Monday to begin
focusing on healthcare because of the vastly different experiences the
two states have had with the law. In Arkansas, which has embraced
Obamacare, the uninsured rate has plummeted from 22.5% in 2013 to 9.1%
in the first half of 2015, the largest decline of any state,
according to Gallup surveys. By contrast, Louisiana has seen its
uninsured rate decline less than half as much, falling from 21.7% to
16.3%. The state's health indicators -- including life
expectancy-- are among the worst in the nation.
Jeanne's Groan #9643 ... It seems that Republicans against raising the minimum wage are actually arguing that if you are stuck in a low paying job, it just a case of your gross income pittance.
September 20, 2015 (from the Commonwealth Fund)
ABSTRACT: In addition to expanding and reforming most of the nation's system of health insurance coverage, the Affordable Care Act (ACA), otherwise known as "Obamacare," contains numerous provisions intended to resolve underlying problems in how health care is delivered and paid for in the United States. These provisions focus on three broad areas: testing new delivery models and spreading successful ones, encouraging the shift toward payment based on the value of care provided, and developing resources for system-wide improvement. This brief describes these reforms and, where possible, documents their initial impact at the ACA's five-year mark. While it is still far too early to offer any kind of definitive assessment of the law's transformation-seeking reforms, it is clear that the ACA has spurred activity in both the public and private sectors, and is contributing to momentum in states and localities across the U.S. to improve the value obtained for our health care dollars.
addition to its more familiar health insurance coverage reforms, the
ACA contains numerous provisions that directly target how health care
is organized, delivered, and paid for in the United States. These
provisions take aim at the well-known shortcomings of the U.S. health
system, from the inefficiency and high cost of our predominantly
fee-for-service system to the extreme variability in the quality of
care patients receive from region to region. Building on
existing reform models in the private and public sectors, the law
takes multiple, complementary approaches to addressing the health
system's longstanding problems. These center on:
With Obamacare now five years old, this brief reviews these approaches and reports on the early impact of specific reforms and initiatives for which reliable data are available. Because many of these provisions are still in the early stages of implementation and testing, it is difficult, if not impossible, to make any definitive assessment of their impact. Nevertheless, it is useful at the five-year mark to review some of the law's delivery and payment reforms in some detail and reflect on the experience of patients, providers, and payers as these profound changes unfold.
NEW MODELS FOR DELIVERING HEALTH CARE
Accountable Care Organizations
In 2015, there are more than 400 Shared Savings ACOs
serving nearly 7.2 million beneficiaries, or 14 percent of the
Medicare population. While these participation numbers have exceeded
expectations, results from the program's first year of operation,
2013, were mixed. Of the 220 Shared Savings ACOs that year, only 52
were able to meet quality-of-care benchmarks and keep spending below
budget targets; these ACOs generated $700 million in total savings and
roughly $315 million in shared-savings bonuses (Exhibit 1).
Another 60 ACOs kept spending under their targets but either did not
fulfill their requirements to measure the quality of care delivered to
patients or did not reduce spending enough to meet the minimum
criteria to share in savings.
The majority of the participating ACOs have opted for one-sided risk, which means they can share in savings produced but are not subject to paying a share of the losses incurred if spending exceeds targets. A key question for CM2 officials is how they can sustain participation in the future while encouraging and supporting providers to assume greater financial risk. A global budget covering all patients is one potentially important strategy for encouraging clinicians to deliver care in innovative ways, invest in value-producing services that are generally not currently reimbursable (such as taking time to email or educate patients), and devote resources to infrastructure enhancements (such as information technology systems) that improve coordination with other providers.
However, most providers across the country have limited
experience in managing care to a budget and limited capacity to
coordinate care with other providers. Hence, many are not ready to
take on the extra financial risk. For providers equipped to test more
advanced payment models and stringent quality thresholds,
has launched the much smaller Pioneer ACO program, which is
administered by the newly created Center for Medicare and Medicaid
Innovation. Known as the
Innovation Center, this agency has the authority to test and
nationally expand new models that are proven to reduce health care
costs while maintaining or improving quality of care. The idea is that
lessons learned from the Pioneer ACOs can be incorporated into the
Shared Savings Program.
In recognition of the challenges providers face to be successful Medicare ACOs, CM2 is allowing providers to take it slow by adopting the one-sided risk model for at least three years and by getting credit for simply reporting on quality measures in the first year. (See Exhibit 5 on page 8.) In addition, low-cost loans are being made available to help spread the model to smaller provider organizations and those in rural areas with limited start-up capital; in fact, one rural organization, Rio Grande Valley ACO, had achieved one of the highest levels of savings as of 2014. ACOs that have proved successful from the start tend to make investments in information technology systems, data analytic tools, and the necessary staff to identify high-risk patients and closely monitor their care.
Medicare's ACO programs are likely to evolve with the
accumulation of experience. An important marker of impact to watch
will be whether ACOs' investments improve outcomes for patient
populations beyond Medicare.
Comprehensive Primary Care Initiative. This national initiative involving 29 payers (excluding CM2 ), nearly 500 providers, and some 2.5 million patients is testing a new way to deliver and pay for care that is designed to improve access, coordination, and chronic disease management while engaging patients and their caregivers. The program offers participating physician practices enhanced payment, technical assistance, and ongoing feedback on performance. Evaluation results show that in the initiative's first year, spanning October 2012 to September 2013, the practices generated enough savings to cover most of the $20 per-member, per-month care management fee paid on average by CM2 (although not enough to produce net savings overall). While there was considerable variation in performance among the seven participating U.S. regions, across all markets emergency department visits decreased by 3 percent and hospital admissions by 2 percent after year1. Significant effects on quality were few.2
Multi-Payer Advanced Primary Care Practice
Demonstration. Medicare has joined eight state-sponsored pilot
programs involving Medicaid and private insurers to test the impact of
per-member, per-month fees paid to primary care sites for providing
medical home services.3
In the demonstration's first
full year of operation, 2012, more than 3,800 providers in 700
practices serving 2.2 million patients participated. Recent evaluation
results estimate $4.5 million in savings generated in year one,
translating to a return on investment of $1.35 for every $1 Medicare
paid out. In Vermont and Michigan, growth in Medicare fee-for-service
health care spending significantly slowed as hospital inpatient care
expenditures fell. There is less evidence, however, that the state
initiatives were able to reduce hospitalizations, readmissions, and
emergency department visits.4
REFORMING PROVIDER PAYMENT
Most of the new payment models are
still in their early phases, and evidence of their impact is far from
definitive. Many initiatives have adopted an incremental approach to
financial accountability, often starting with pay-for-reporting or
bonus-only options (Exhibit 5). The gradual approach recognizes that
the type of structural change required to be successful under
risk-based payment systems takes time, a concern repeatedly voiced by
Jeanne's Groan #9441: No one is born a politician, they're made. Which may explain why so many of them have a screw loose.
September 16, 2015
House Energy and Commerce members signaled interest
last week in a bipartisan plan that would amend the Affordable Care
Act (Obamacare) to keep employers with 51 to 100 workers from having
to comply with more stringent insurance coverage requirements.
September 15, 2015
With the GOP-controlled House of Representatives poised
to vote on yet another bill to cripple President Obama's health care
law and the multitudinous GOP candidates finding success in catering
to their conservative constituencies with new hues and cries for
"REPEAL AND REPLACE" (with what is always only whispered and masked in
vagueness), the question arises: Why do Republicans persist in their
so-far futile efforts?
GOP PLANS FOR PRIVATIZING MEDICARE
September 14, 2015
Many Americans are mired in a now 30+ years-old conservative suckhole and have a total misunderstanding of the word "socialist" (to most Americans "socialism" equals "communism"). With 35 years of "inside-the-beltway" political experience under my belt, to me this is more than enough proof of the fact that Bernie Sanders can never be elected president of the United States ...
Should he, by some chance, win the Democratic Party's nomination next summer, he would be blown out of the water and swamped by a large portion of that Koch brothers-pledged $900 million spent "informing" Americans that Sanders is an "avowed socialist" ... Americans do not know what socialism is, they have been brainwashed by 65 years of cold war rhetoric telling them that socialism is "bad", worse than bad, it is "evil," and most of them will believe this to be true and will be overwhelmed by the lies that will be spread. Today, most Americans have never even heard of Bernie Sanders and when they do hear about him it will be under a massive Koch-financed umbrage of lies ... today they do not know that Sanders admits to being a socialist and when they do learn this, they will turn away in droves not because his message is wrong but because they will perceive it as un-American ...
I am faced with a serious conundrum (not the first in my life BTW <smile>) ... my children, grandchildren, and many of my friends are jumping on the Sanders bandwagon (all too frequently bad-mouthing the other Democratic candidates in the process) ... so let me say, I admire Bernie Sanders, I agree with 95% of the things he is supporting. America's "St. Ronald of Reagan conservative suckhole" is destroying our vaulted "middle class" and we have to act to change the nation's direction. But I am also a well-worn down political pragmatist and I want to win in 2016 ... we have to win in 2016 ... at least 3 members of the Supreme Court will be stepping down over the coming years, if a "President Scott Walker" or "President Jeb Bush" or worse, a "President Ted Cruz" is in office, it will be a national disaster.
Americans don't change their political thinking that quickly and he would lose not only the presidency if by some chance he wins the Democratic nomination, but would drag down the Congress with him to super majorities for right-wing loonies to continue their destruction of America's middle class ... Should Bernie Sanders get the nomination, he has my vote and apparently that of at least 312 of my friends and family, now all we need is 69,999,687 more to vote for him and make sure that they are in the right states, like Florida and Ohio (ask Al Gore about that) ... and oh by, the way, wait until the average Joe American hears that Bernie is an avowed socialist ... his policies may be great and wonderful, but they'll never get past the $900 million in Koch money that will scream "SOCIALISM" incessantly should he actually get the nomination ... massive crowds showed up at Eugene V. Debs rallies in the 30's ...and he won less than 2% of the vote ... naive views of the US political system will guarantee a right-wing Supreme Court that will last until your children have grandchildren ...
Democratic progressives like Elizabeth Warren and Bernie Sanders play a critical role, but we are a deeply divided nation ...Senator Warren knows her job (and she has openly stated this and it should also be that of Bernie Sanders,) is to hold Hillary's feet to the fire and keep her focused on progressive issues ... neither Warren or Sanders can win with just lefty votes and would be killed in the money contest by the right-wing nutcases ...Democrats just have to keep their enthusiasm in check and avoid bad-mouthing Hillary in such a way as to be destructive to Democratic chances in the 2016 elections Ö Republican neo-cons financed by the likes of the Koch brothers are feeding this anti-Hillary frenzy on the left and too many Democrats are selling themselves to the right .
September 13, 2015
One of the main ways the Affordable Care Act (Obamacare) seeks to reduce health care costs is by encouraging doctors, hospitals and other health care providers to form networks that coordinate patient care and become eligible for bonuses when they deliver that care more efficiently. The law takes a carrot-and-stick approach by encouraging the formation of accountable care organizations (ACOs) in the Medicare program. Providers make more if they keep their patients healthy. About 6 million Medicare beneficiaries are now in an ACO, and, combined with the private sector, at least 744 organizations have become ACOs since 2011. An estimated 23.5 million Americans are now being served by an ACO. You may even be in one and not know it. While ACOs are touted as a way to help fix an inefficient payment system that rewards more, not better, care, some economists warn they could lead to greater consolidation in the health care industry, which could allow some providers to charge more if they're the only game in town.
ACOs have become one of the most talked about new ideas in Obamacare. Here are answers to some common questions about how they work:
What is an accountable care organization?
An ACO is a network of doctors and hospitals that shares financial and medical responsibility for providing coordinated care to patients in hopes of limiting unnecessary spending. At the heart of each patient's care is a primary care physician. In Obamacare, each ACO has to manage the health care needs of a minimum of 5,000 Medicare beneficiaries for at least three years. Think of it as buying a television, says Harold Miller, president and CEO of the Center for Healthcare Quality & Payment Reform in Pittsburgh, Pa. A TV manufacturer like Sony may contract with many suppliers to build sets. Like Sony does for TVs, Miller says, an ACO brings together the different component parts of care for the patient -- primary care, specialists, hospitals, home health care, etc. -- and ensures that all of the "parts work well together." The problem with most health systems today, Miller says, is that patients are getting each part of their health care separately. "People want to buy individual circuit boards, not a whole TV," he says. "If we can show them that the TV works better, maybe they'll buy it," rather than assembling a patchwork of services themselves.
Why did Congress include ACOs in the law?
As lawmakers searched for ways to reduce the national deficit, Medicare became a prime target. With baby boomers entering retirement age, the costs of caring for elderly and disabled Americans are expected to soar. The health law created the Medicare Shared Savings Program. In it, ACOs make providers jointly accountable for the health of their patients, giving them financial incentives to cooperate and save money by avoiding unnecessary tests and procedures. For ACOs to work, they have to seamlessly share information. Those that save money while also meeting quality targets keep a portion of the savings. Providers can choose to be at risk of losing money if they want to aim for a bigger reward, or they can enter the program with no risk at all. In addition, the Centers for Medicare & Medicaid Services (CM2) created a second strategy, called the Pioneer Program, for high-performing health systems to pocket more of the expected savings in exchange for taking on greater financial risk.
In 2014, the 20 ACOs in the Medicare Pioneer Program and 333 in the Medicare Shared Savings generated $411 million in total savings but after paying bonuses, the program resulted in a net loss of $2.6 million to the Medicare trust fund. That's far less than 1 percent of Medicare spending during that period. Still the program is expected to be expanded and Health and Human Services Secretary Sylvia Burwell has set a goal of tying 50 percent of all traditional Medicare payments to quality or value by 2018 through new payment models, including ACOs.
How are ACOs paid?
In Medicare's traditional fee-for-service payment system, doctors and hospitals generally are paid for each test and procedure. That drives up costs, experts say, by rewarding providers for doing more, even when it's not needed. ACOs don't do away with fee for service, but they create an incentive to be more efficient by offering bonuses when providers keep costs down. Doctors and hospitals have to meet specific quality benchmarks, focusing on prevention and carefully managing patients with chronic diseases. In other words, providers get paid more for keeping their patients healthy and out of the hospital. If an ACO is unable to save money, it could be stuck with the costs of investments made to improve care, such as adding new nurse care managers. An ACO also may have to pay a penalty if it doesn't meet performance and savings benchmarks, although few have opted into that program yet. ACOs sponsored by physicians or rural providers, however, can apply to receive payments in advance to help them build the infrastructure necessary for coordinated care -- a concession the Obama administration made after complaints from rural hospitals.
In 2014, the third year of the Medicare ACO program, 97 ACOs qualified for shared savings payments of more than $422 million.
How do ACOs work for patients?
Doctors and hospitals will likely refer patients to hospitals and specialists within the ACO network. But patients are usually still free to see doctors of their choice outside the network without paying more. Providers who are part of an ACO are required to alert their patients, who can choose to go to another doctor if they are uncomfortable participating. The patient can decline to have his data shared within the ACO.
Who's in charge -- hospitals, doctors or insurers?
ACOs can include hospitals, specialists, post-acute providers and even private companies like the drug chain CVS. The only must-have element is primary care physicians, who serve as the linchpin of the program. In private ACOs, insurers can also play a role, though they aren't in charge of medical care. Some regions of the country, including parts of California, already had large multi-specialty physician groups that became ACOs on their own by networking with neighboring hospitals.
In other regions, large hospital systems are scrambling to buy up physician practices with the goal of becoming ACOs that directly employ the majority of their providers. Because hospitals usually have access to capital, they may have an easier time than doctors in financing the initial investment, for instance to create the electronic record system necessary to track patients. Some of the largest health insurers in the country, including Humana, UnitedHealth and Aetna, have formed their own ACOs for the private market. Insurers say they are essential to the success of an ACO because they track and collect the data on patients that allow systems to evaluate patient care and report on the results.
If I don't like HMOs, why should I consider an ACO?
ACOs may sound a lot like health maintenance organizations. "Some people say ACOs are HMOs in drag," says Kelly Devers, a senior fellow at the Urban Institute. But there are some critical differences -- notably, an ACO patient is not required to stay in the network. Steve Lieberman, a consultant and senior adviser to the Health Policy Project at the Bipartisan Policy Center in Washington, D.C., explains that ACOs aim to replicate "the performance of an HMO" in holding down the cost of care while avoiding "the structural features that give the HMO control over [patient] referral patterns," which limited patient options and created a consumer backlash in the 1990s. In addition, unlike HMOs, the ACOs must meet a long list of quality measures to ensure they are not saving money by stinting on necessary care.
What could go wrong?
Many health care economists fear that the race to form ACOs could have a significant downside: hospital mergers and provider consolidation. As hospitals position themselves to become integrated systems, many are joining forces and purchasing physician practices, leaving fewer independent hospitals and doctors. Greater market share gives these health systems more leverage in negotiations with insurers, which can drive up health costs and limit patient choice. But Lieberman says while ACOs could accelerate the merger trend, consolidations are already "such a powerful and pervasive trend that it's a little like worrying about the calories I get when I eat the maraschino cherry on top of my hot fudge sundae. It's a serious public policy issue with or without ACOs."
Are ACOs the future of health care?
ACOs are already becoming pervasive, but they may be just an interim step on the way to a more efficient American health care system. "ACOs aren't the end game," says Chas Roades, chief research officer at The Advisory Board Company in Washington. One of the key challenges for hospitals and physicians is that the incentives in ACOs are to reduce hospital stays, emergency room visits and expensive specialist and testing services -- all the ways that hospitals and physicians make money in the fee-for-service system, explains Roades. He says the ultimate goal would be for providers to take on full financial responsibility for caring for a population of patients for a fixed payment, but that will require a transition beyond ACOs.
This article was produced by Kaiser Health News with support from The SCAN Foundation.
HOW AN ACO WORKS (Graphically-designed for the conceptually-impaired like me)