ACA

Obamacare Unsustainable

Geyman's Books

Dr. John Geyman has published his latest book on the state and future of American health care.* He has written a series of books on this subject over the last 13 years.** His latest, “How Obamacare is Unsustainable” should be must reading for every congressmen, CMS employee and medical reporter and blogger as well as President Obama and his staff. It should be recommended reading for everyone else concerned about health care in the United States.

Dr. Geyman discusses the failure of the Affordable Care Act (ACA) to effectively address the four biggest challenges of health care reform: restricted access, increasing costs, increasing unaffordability even for people with insurance, and poor quality of care compared to the rest of the industrial world. He first reviews the history of the corporation led charade that created the byzantine ACA. Political corruption, lobby money, and media entanglements with corporate stakeholders (especially the pharmaceutical and insurance industries) disfigured the initial goals beyond recognition.

In Chapter 10, after reviewing where we stand now, 5 years into the ACA, he elaborates on the ten lessons we should have learned (and were predictable):

1) Health care “reform’ through the ACA was framed and hijacked by corporate stakeholders, themselves in large part responsible for system problems of health care and dedicated to perpetuating their self-interests in an unfettered health care marketplace.

2) You can’t contain health care costs by leaving for-profit health care industries to pursue their business “ethic” in a deregulated marketplace.

3) You can’t reform the delivery system without reforming the financing system.

4) The private insurance industry does not offer enough value to be bailed out by government.

5) It is futile to embark on unproven and disproven incremental tweaks to our present system while ignoring health policy and experience around the world.

6) In order to gain the most efficiency of insurance coverage we need the largest possible risk pool to spread the risk and avoid adverse selection.

7) The ACA is a massive bailout of private interests profiting on the backs of sick or injured Americans.

8) The single-payer alternative was considered “politically unfeasible” by being “too disruptive” to the existing system; instead, look at how disruptive the ACA has been compared to the simplified single-payer alternative.

9) The ACA is unaffordable for many patients and their families, is byzantine in its complexity, and is unsustainable in the long run.

10) We cannot trust many states to assure an adequate safety net for the insured and underinsured.

Dr. Geyman goes on to define the need for, and the barriers to the development of a single-payer system in the United States. He describes what a single-payer system would look like and what the political prospects are for developing such a system.

This evidence-based analysis of our health care non-system offers the most comprehensive, accurate, and functional map of the road to universal health care in the United States.

* Geyman, JP. How Obamacare is Unsustainable: Why We Need a Single-Payer Solution for All Americans. Friday Harbor, WA. Copernicus Healthcare, 2015.

**A list of books by Dr. John Geyman

  •  Health Care in America                                                 2002
  • The Corporate Transformation of Health Care               2004
  • Falling Through the Safety Net                                       2005
  • Shredding the Social Contract                                        2006
  • The Corrosion of Medicine                                              2008
  • Do Not Resuscitate                                                          2008
  • Hijacked                                                                           2010
  • Breaking Point                                                                  2011
  • The Cancer Generation                                                    2012
  • Health Care Wars                                                             2012
  • How Obamacare is Unsustainable                                   2015

To see Dr. Geyman’s biography and web site visit….…http://www.johngeymanmd.org/PNHP-profile-jgeyman-2007.html & http://www.johngeymanmd.org/

Service Model, Not Business Model

Jim Flower has written an excellent article in Hospitals & Health Networks stating, ”It’s time to Rebuild Health Care’s Business Model”. He nicely portrays the unworkable elements of our present system and concludes that there is no way of tweaking the model to make it work. As he says, “The health care system, payers and providers playing the Default Model Game, are delivering an unreliable, unguaranteed, financially and medically dangerous product to their real customers — the large purchasers and the consumers of health care. This is not stable.”  Unfortunately he runs out of steam when it comes to the solution. Admittedly, he is speaking to hospitals and health networks and not to individual patients, policy makers, CMS, legislators, etc. His recommendations to get out of the fee-for-service business as much as possible, drive down internal costs and bid actual prices are, again, just different ways of playing the same old game. They don’t alter the present underlying attitudes of treating health care as a commercial, for-profit business rather than as a humane service. We have to grasp the knowledge that health insurance is a no-value-added business, that the patent protected pharmaceutical industry is avaricious, hospital systems are bounced between profit-making and forced service and physicians are losing their sense of their profession as a “calling”. Reforming business models is not going to change these fundamental dynamics.  If we want affordable, accessible and universal health care we need to improve Medicare and expand it to cover everybody from the day they are born and finance it through a single payer, multiple provider system dedicated to health care reform.  

Pioneer ACOs Defended

This week the Centers for Medicare & Medicaid Services (CMS) Innovation Center published an update on the Pioneer ACO Model experience. This is definitely a PR piece and it comes off as a desperate salvage attempt. This CMS sponsored program started in 2012 with 32 hand-picked, high-functioning, EMR savvy, medical care organizations. The purpose was to explore the cost-saving and quality enhancing potential of a model Accountable Care Organization (ACO) for the Medicare population. Financial incentives are offered to those organizations who beat certain cost reduction goals. Starting last year penalties will be applied to those ACO’s whose performance falls below established levels. This happened to 6 of the 23 remaining ACO.s. Eleven of them earned shared savings with an average of $4.2 million. The usual bag of quality of care metrics (very few are outcomes) is monitored. In 2013 9 of these organizations pulled out of Pioneer and recently Sharp Health Care in San Diego left. CMS reported $87 million in savings for 2012 and $96 million in 2013. These are not very impressive numbers for 669,135 Medicare beneficiaries. It’s obvious that the program leaves much to be desired especially when one considers that all of these organizations are atypically sophisticated. Nevertheless one of the departing organizations was the University of Michigan. They stood to gain some shared savings but apparently they quit because of administrative complexity and lack of computer interoperability. Interestingly CMS doesn’t reveal what the start-up and maintenance costs have been for the participants. “Innovation pods” have been developed to help generate that information but I have not been able to find any published data.. Apparently some of last year’s cost-saving came from a waiver CMS gave to Pioneer for the 3-day hospitalization rule for admission to a skilled nursing facility. Of course that waiver and those savings could be applied to all Medicare recipients without involving an ACO. So in this instance the savings figure has been “doctored.” Assignment Instability and Alignment are huge problems in any grouped outpatient plan. In a recent study only 66% of beneficiaries were consistently assigned to one ACO over a two year period. To make matters worse, 66.7% of office visits with specialists were outside of the ACO. And, of course, that presents a problem with applying quality metrics. CMS uses claims analyses to assign patients to an ACO. They are considering allowing patients to identify their primary physician and determine assignment based on that. If that worked it still wouldn’t solve the problem of leakage where a patient receives services outside of the organization. The last paragraph of this published viewpoint is interesting. Whereas the piece started out with beautifying words such as “collaborative”, “rich”, “shared”, “sophisticated”, etc., we then see “recognition of the need for more tools.” And finally, “challenging”, “continues to mature”, “fueled by”, “as ACO’s become…”, “as CMS becomes more effective…”, “apply lessons learned”, “development of new models” and ”CMS will evaluate whether these Pioneer results warrant expansion nationally.” And the final throw-away pitch, “Early success in the Pioneer model suggests that in the long term, accountable care will offer patients the improved outcomes they deserve and ACOs the sustainable business model they need to stay focused on delivering high-value care.” In other words, it isn’t working.

Posted 9/17/2014

Too Late, Too Little: Too Much, Too Soon

We Need an Improved Medicare

Introduction
We should all be looking at ways we can increase the quality of our medical care and decrease the costs at least to equal the accomplishments of the rest of the industrialized world. It makes sense to work on improving Medicare so that when we finally exhaust all of the other alternatives (the American way) and adopt a single payer system, “Improved Medicare for All” we will already have accomplished a lot of the improvement. But Centers for Medicare and Medicaid Services (CMS), while administering Medicare and the Affordable Care Act, seems determined to spend a lot of money on “experiments” that don’t even make sense much less have any evidence to suggest that they are viable.  And they seem to spend no effort on predicting unintentional consequences. The effect of these diversions is going to be a further degradation of the medical care available not only to the Medicare eligible but to the entire population. The latest example is the new twist on Chronic Care Management (CCM) services. This was recently discussed in the New York Times in an article by Robert Pear, published August 16, 2014.  This is a plan to pay doctors a separate fee of $41.92 a month for managing the chronic care of some Medicare patients after January 1, 2015. This is for non face-to-face development and revision of care plans, communication with other care providers, prescription drug management, etc. see ADDENDUM. It will be classified as a G code with the description,” Chronic care management services furnished to patients with multiple (two or more) chronic conditions expected to last at least 12 months, or until the death of the patient, that place the patient at significant risk of death, acute exacerbation/ decompensation, or functional decline; 20 minutes or more; per 30 days.”

Background
There is no question that care coordination is an increasing problem as patient care has transitioned to specialists and hospitals. Medical care of patients with chronic conditions is especially disjointed and plagued with discontinuities. This breakdown in care over the last 20 years has occurred as primary care, basically family practice, has been driven back to an office based medicine with little communication with hospitals, specialists, urgent care centers and other health care providers.

The Problems
The creators of this program have done an excellent job of incorporating many of the concepts that are being developed for complex ambulatory medical care, including the Leap Project.

Unfortunately the Chronic Care Management formula presents a number of consequences (which should be foreseen);The number of patients who will fall within the eligible parameters will probably be less than half of the Medicare population. And, in turn, the Medicare population represents  16.5% of the total population in the United States.

Excel Table3

This creates two major problems: The small, age defined group of beneficiaries will not provide ample sampling size or randomness to derive useful data for improving chronic care over-all. The additional fixed costs to medical providers for participation will be very high considering the small percentage of their practices affected and the reimbursement limited to the Medicare panel.

The matter of cost to the practitioners will limit participation to large groups and corporations. Rural and underserved areas will again be excluded from some of the benefits of Medicare. Keep in mind that as of 2010 almost half of primary care physicians saw their patients in offices of one or two physicians. Since then, of course, many have left practice.

  • Certified Electronic health records are required in this new plan but practice size is a major determinant of physicians’ use of EMRs and HIT capacity, including exchanging patient information electronically and providing electronic access to their patients. Half of physicians in solo practices report using EMRs, compared to 90 percent of those in practices with 20 or more physicians; likewise, there is a 4-fold difference between solo and large practices in achieving multifunctional HIT capacity (11 vs. 45 percent).
  • Participant practices will have to have a supervised staff person on call, after-hours, 24/7,  to address the “urgent chronic care needs” of the patients.
  • Tremendous amounts of paperwork, manpower and teamwork will be required to monitor, coordinate, and document all of the requirements of this plan. For a recent CMS list of these requirements see the ADDENDUM below.
  • Deborah N. Peikes discovered in her analysis of the similar team-based Comprehensive Primary Care Initiative that “At baseline, most CPC initiative practices used traditional staffing models and did not report having dedicated staff who may be integral to new primary care models, such as care coordinators, health educators, behavioral health specialists, and pharmacists. Without such staff and payment for their services, practices are unlikely to deliver comprehensive, coordinated, and accessible care to patients at a sustainable cost.”

It is understood that from the perspective of Medicare the high costs of the top 20% of the chronic care patients create the greatest expenditure. But our medical cost and care problems are much bigger than this small corner of the landscape. And all we have to help us is CMS with Medicare, Medicaid, and the Affordable Care Act. Of course if we had everyone in and nobody out we could tackle the bigger problems.

This program is serving as a diversion from solving the problem of adequate compensation for primary care in general. Meanwhile, our family practice workforce continues to decline while Nero fiddles. If as much energy had been put into solving the RVU and physician income disparities we could be on our way to re-establishing a primary care base. Unfortunately the new proposal only aggravates these problems. Two of the major factors that are driving medical students away from primary care is the low future income combined with the high student debt.  The third problem is the large burden of office practice administration. The cost of compliance and documentation with all of the existing programs is already overwhelming . This leaves the primary care profession with no time left over to worry about coordination but with a big desire to abandon this field of medicine. CMS has no solution to this and yet they want to add one more program that requires more continuous documentation, appeals of denial to file, cost of extra personnel, etc. CMS states that as part of the new service, doctors will assess patients’ medical, psychological and social needs; check whether they are taking medications as prescribed; monitor the care provided by other doctors; and make arrangements to ensure a smooth transition when patients move from a hospital to their home or to a nursing home. This workload is multiplied by the fact that the target patients are the sickest and oldest. They have a high mortality rate so the paperwork starts all over for the next replacement on the panel. For $42/month.

The Solution
Who in primary care is left to carry out the program?  Basically, it will be members of large group practices and hospital and other institutional employers in urban centers. The growing supply/demand incongruence of available primary care physicians will make that option even more profitable for the physicians. That leaves out the rest of America. And the uninsured and underinsured will continue to be left out in the cold. We need a broader vision. We need an Improved Medicare for All.

ADDENDUM
(CMS Statement)

“To assist stakeholders in commenting, we remind you of the elements of the current scope of service for CCM services that are required in order for a practitioner to bill Medicare for CCM services as finalized in the CY 2014 final rule with comment period. We would note that additional explanation of these elements can be found at 78 FR 74414 through 74428. The CCM service includes:

  • Access to care management services 24-hours-a-day, 7-days-a-week, which means providing beneficiaries with a means to make timely contact with health care providers in the practice to address the patient’s urgent chronic care needs regardless of the time of day or day of the week.
  • Continuity of care with a designated practitioner or member of the care team with whom the patient is able to get successive routine appointments.
  • Care management for chronic conditions including systematic assessment of patient’s medical, functional, and psychosocial needs; system-based approaches to ensure timely receipt of all recommended preventive care services; medication reconciliation with review of adherence and potential interactions; and oversight of patient self-management of medications.
  • Creation of a patient-centered care plan document to assure that care is provided in a way that is congruent with patient choices and values. A plan of care is based on a physical, mental, cognitive, psychosocial, functional and environmental (re)assessment and an inventory of resources and supports. It is a comprehensive plan of care for all health issues.
  • Management of care transitions between and among health care providers and settings, including referrals to other clinicians, follow-up after a beneficiary visit to an emergency department, and follow-up after discharges from hospitals, skilled nursing facilities, or other health care facilities.
  • Coordination with home and community based clinical service providers as appropriate to support a beneficiary’s ’s psychosocial needs and functional deficits.
  • Enhanced opportunities for a beneficiary and any relevant caregiver to communicate with the practitioner regarding the beneficiary’s care through, not only telephone access, but also through the use of secure messaging, internet or other asynchronous non face-to-face consultation methods.Similarly, we remind stakeholders that in the CY 2014 final rule, we established particular billing requirements for CCM services that require the practitioner to:
  • Inform the beneficiary about the availability of the CCM services from the practitioner and obtain his or her written agreement to have the services provided, including the beneficiary’s authorization for the electronic communication of the patient’s medical information with other treating providers as part of care coordination.
  • Document in the patient’s medical record that all of the CCM services were explained and offered to the patient, and note the beneficiary’s decision to accept or decline these services.
  • Provide the beneficiary a written or electronic copy of the care plan and document in the electronic medical record that the care plan was provided to the beneficiary.
  • Inform the beneficiary of the right to stop the CCM services at any time (effective at the end of a 30-day period) and the effect of a revocation of the agreement on CCM services.
  • Inform the beneficiary that only one practitioner can furnish and be paid for these services during the 30-day period. With the addition of the electronic health record element that we are proposing, we believe that these elements of the scope of service for CCM services, when combined with other important federal health and safety regulations, provide sufficient assurance that Medicare beneficiaries receiving CCM services will receive appropriate services. However, we remain interested in receiving public feedback regarding any meaningful elements of the CCM service or beneficiary protections that may be missing from these scope of service elements and billing requirements. We encourage commenters, in recommending additional possible elements or safeguards, to provide as much specific detail as possible regarding their recommendations and how they can be applied to the broad complement of practitioners who may furnish CCM services under the PFS.”
    Federal Register Vol 79 No. 133 July 11, 2014

Primary Care Disappearing

This article from the AAFP discusses a problem that is only going to get worse. As today’s medical students avoid primary care residencies we are losing the next generation of mentors. This will become irreversible at some point unless we overhaul the income disparities and student loan indebtedness to encourage primary care choices. Increased respect in medical training and elimination of the bureaucratic disincentives for private practice would also help. http://www.aafp.org/news/education-professional-development/20140706preceptstudy.html?cmpid=em_20318028_B1  The ACA doesn’t provide the long term vision and system coordination necessary to reverse the downward spiral.

NARROW NETWORKS: Less Choice, More Cost Shifting

As the Affordable Care Act (ACA) unfolds we are now entering the era of the health insurance exchanges. In response to the law’s various requirements the insurance industry is remodeling its concept of provider networks to create new “narrow” networks for the individual and small group markets.  This is a throwback to the failed HMO concept of severely limiting patients’ choices of physicians and hospitals in a cynical effort to control costs. In the exchanges the insurance companies must offer products that cover the list of Essential Health Benefits (EHB) and  their plans must meet actuarial values (AV) specified for various ”Metal” levels, e.g., Bronze =60%, Silver=70%, etc. The AV is the expected percentage of all the medical expenses that the insurance company will pay in that category. Enrollment in a plan cannot be denied on the basis of pre-existing medical problems and there can be no lifetime cap on covered expenses.

In response to these requirements most of the plans being designed in the various states use a narrow list of doctors, hospitals, laboratories, etc. The insurers have large amounts of data to guide them in choosing the least expensive providers. This choice does not concern itself with quality of care no matter how the insurance companies try to frame it. The required size and makeup of the plans is rather loosely defined with federal rules stating that the insurers “must maintain a network of a sufficient number and type of providers, including providers that specialize in mental health and substance abuse, to assure that all services will be available without unreasonable delay.” State rules are generally just as vague.

Every day we now read about the latest shift to narrow networks. In Massachusetts, insurer Harvard Pilgrim launched its Focus Network, plugging 10 percent lower premiums. In California, Blue Shield has a number of SaveNet HMO plans that contract with select doctor and hospital groups, creating networks averaging a little more than half the size of its standard ones. For example, one serving Marin and Sonoma counties will offer a network of about 100 primary care doctors and 325 specialists. Anthem Blue Cross Blue Shield in Wisconsin and Aurora Health Care have secured the first major company to offer their health plan that guarantees cost savings of at least 8 percent for employers (not for patients). This is occurring all over the country. A McKinsey & Co. analysis found 47 percent of 955 plans proposed for the online marketplaces were for health maintenance organizations or plans with similar designs. The New York Times recently published an article by Robert Pear highlighting some of the concerns about this problem. He quotes a recent Pricewaterhousecoopers HealthResearch Institute report that discussed insurers bypassing major medical Centers in numerous states including California, Illinois, etc.

When insured by a narrow network policy it becomes a hazard course for anyone (you) trying to choose a new physician, replace the physician who has known you for years or find a specialist, especially a sub-specialist. “Yes, we have a cardiologist in your area. No, we don’t have an electrophysiologist in your plan. ” Or maybe your primary care physician feels that the best orthopedic surgeon for your type of problem is one that isn’t on your narrow plan’s list. Or the specialist in the network wants you to go to the nearby university medical center. If you make a mistake and go to a non-plan hospital you may end up with thousands of dollars of unpaid bills.  Or the hospital may be on the list but the contracted group of “hospitalist” physicians may not be. And maybe you went to that hospital because you were out of town on vacation. With these hurdles add the fact that the narrower the network the fewer the alternatives and the longer one will have to wait for an appointment.

The plans being offered are low priced and have high deductibles and co-pays. They will appeal to the young and healthy who, at the time of enrollment, haven’t needed medical care.  Patients with multiple and complex medical needs are not going to be satisfied with the limited coverage, limited physicians (may not even include their long term primary care physicians and specialists), and limited hospitals, etc. This gives the insurance companies an opportunity to cherry-pick the least costly patients without violating the regulation against denial for pre-existing illnesses. When they develop their new narrow networks they also refine their cherry-picking techniques even further by mining the usage data from their old networks to weed out the providers who care for the most complex cases. Furthermore they also can count on costs being diverted to the patient when a patient’s care is acquired outside the narrow network either intentionally or unintentionally.  All of this is done under the ruse of cost-containment. The goal is to take in as much money as possible and to pay out as little as possible.

The shell game of cost-shifting to the patient is not cost containment. Of course all of these problems of cost, choice and continuity of care would be non-existent in a system of universal coverage such as single payer medicine.

 

Suggested Reading:

Insurers limit doctors, hospitals in state-run exchange plans
Exclusive arrangements and tight networks become more common as insurers and government officials search for ways to hold down medical costs.
   May 24, 2013|By Chad Terhune, Los Angeles Times

Can narrow networks boost exchange coverage?
   January 25, 2013 | By Dina Overland, FierceHealthPayer

HMO-Like Plans May Be Poised To Make Comeback In Online Insurance Markets
   Jan 22, 2013 |By Julie Appleby KHN Staff Writer, Kaiser Health News

Narrow network plans could drive up costs
   September,19,2013|By Dina Overland, FierceHealthPayer

 Insurers limiting doctors, hospitals in health insurance market
   September 14, 2013 | By Chad Terhune, Los Angeles Times

Lower Health Insurance Premiums to Come at Cost of Fewer Choices
   September 22, 2013 |By Robert Pear, The New York Times

Most exchange plans limit member choice
   August 16, 2013 |By Julie Bird, Fiercehealthpayer

 Health Exchanges: Open for Business
   HRI’s Closer Look
PricewaterhouseCoopers Health Research Institute