Sunday, August 30, 2020

Trump Program to Cover Uninsured Covid-19 Patients Falls Short of Promise - The New York Times

Trump Program to Cover Uninsured Covid-19 Patients Falls Short of Promise - The New York Times: Some patients are still receiving staggering bills. Others don’t qualify because conditions other than Covid-19 were their primary diagnosis.

Saturday, August 29, 2020

Another ACO horror story - Kip Sullivan

Vermont is learning that ACOs are no different from HMOs. They don't function as advertised, they encourage consolidation, and you never know what they did with the money they get. Vermont's state auditor released a report on June 26 on a giant Vermont ACO with the ominous name One Care (as in "one ring to rule them all"). One Care was created by the two largest hospital-clinic chains that serve Vermont in 2016. The auditor has two complaints. He says the state has no idea whether OneCare is cutting costs, and it has no idea whether it's improving quality. That's exactly what happened here in MN after our legislature privatized Medicaid and MinnesotaCare in the 1990s. Unfortunately, our legislature and state auditor haven't lifted a finger to address that problem. It's also exactly what's happening with MN's Medicaid ACO program, known as "Integrated Health Partnerships." A former VT commissioner, Patrick Flood, just published this blistering critique of the Green Mountain Board, the agency that is supposed to oversee One Care. Flood praises the auditor's report, and suggests the Green Mountain Board is making the auditor's job even harder by not disclosing data. He quotes the CEO of One Care saying she has no idea why the ACO lost money last year. The great irony of the "accountable care organization" fad is it makes accountability much harder to achieve. Kip

EPI update on health insurance losses and policy recommendations - Don McCanne

Economic Policy Institute August 26, 2020 Health insurance and the COVID-19 shock What we know so far about health insurance losses and what it means for policy By Josh Bivens and Ben Zipperer Although the gold-standard data sources tracking changes in health insurance coverage will not be available until next year, imperfect but available data on job churn and net employment allow us to produce estimates of losses of health insurance coverage since the COVID-19 shock began. These estimates are more accurate than early-crisis estimates, and they account for job gains. Following are key highlights from the report. * In any given month, churn in the labor market—some people losing jobs while other people gain them—means millions of workers newly gain or lose access to employer-sponsored health insurance (ESI) each month. For example, between 2015 and 2019, roughly 2.8 million workers gained access to ESI in each month while 2.7 million workers lost access, leading to a net increase in ESI coverage of just over 100,000 workers each month. * Extreme churn after February 2020 has led to very large losses in ESI coverage. In March and April, for example, new hiring led to 2.4 million workers gaining ESI coverage each month, but historically large layoffs led to 5.6 million workers losing coverage each month. This rate of lost coverage—over 3 million workers—dwarfs a similar calculation for the number of workers losing coverage each month during the biggest job-losing period of the Great Recession (September 2008–March 2009). * While the data documenting labor market churn data are useful, they do not provide the best estimates of ESI losses because they are not the most timely data, nor do they provide the best net measure of employment changes. * Since the onset of the COVID-19 shock to the economy, roughly 6.2 million workers have lost access to health insurance that they previously got through their employer, according to the best measure of net employment change. Our analysis using the monthly, high-quality measure of the total number of jobs in the economy from the Current Employment Statistics (CES) program of the Bureau of Labor Statistics (BLS) is consistent with 9 million workers having lost access to ESI in March and April 2020 but 2.9 million workers having gained coverage between April and July 2020. * Not every worker who loses ESI loses health insurance coverage. Public health insurance rolls are expanding to absorb the enormous ESI coverage losses of recent months. However, they have not expanded enough to absorb everybody who lost job-based coverage. A new government survey measuring the economic consequences of the COVID-19 shock in real time indicates that for every 100 workers who were covered by ESI before losing their job, about 85 retained access to some form of health insurance in the week after they lost their job. * It is likely the case that Medicaid is the dominant alternative source of coverage when people have lost ESI in the COVID-19 shock, as Medicaid rolls have likely expanded by more than 4 million since the COVID-19 shock began. From the Conclusion The inefficiencies and problems caused by the U.S. system of tying access to health insurance to specific jobs is well known. The downsides of employer-based health insurance access have been made spectacularly visible by the COVID-19 shock—a shock that has cost millions of Americans their jobs and their access to health care in the midst of a public health catastrophe. Delinking access to health insurance from specific jobs should be a top policy priority for the long term. The most ambitious and transformational way to sever this link is to make the federal government the payer of first resort for all health care expenses—a “single-payer” plan. The federal government already is the primary insurer for all Americans over the age of 65 and for households with incomes low enough to qualify for Medicaid. The advantages of a single-payer system are large, both in ensuring consistent access to medical providers that households prefer and in restraining the often-rapid growth of health care costs. === Comment by Don McCanne Although the data on changes in employment status and employer-sponsored health insurance due to the COVID-19 pandemic are still preliminary, we do have enough information to know that the impact has been catastrophic. We have long known that tying health insurance to employment has serious unintended consequences, and the experience during this pandemic adds indubitably to the conclusion that it is a bad idea. The authors conclude, "Delinking access to health insurance from specific jobs should be a top policy priority." Further, "The most ambitious and transformational way to sever this link is to make the federal government the payer of first resort for all health care expenses — a 'single-payer' plan." They are absolutely right on target. They further conclude, "Absent a once-and-for-all switch to a single-payer system, policymakers can take smaller steps..." Uh-oh, incrementalism, in this case suggesting perhaps lowering the age of Medicare eligibility, or raising income thresholds for Medicaid eligibility, or adding a public option to the ACA exchanges, perhaps with employer play or pay, etc. These incremental measures increase costs, perpetuate inequities, perpetuate profound administrative waste, and still leave millions uninsured or underinsured. So ignore their optional incremental steps and go for the real thing: the single payer model of an improved Medicare for All. Anything less simply perpetuates far too many of the dysfunctions of our current health care financing system. We've had enough of that.

BCBS and Allina form ACO by Kip Sullivan

According to the article from Modern Healthcare pasted in below, Minnesota's largest insurance company (Blue Cross Blue Shield) just cut a deal with one of the state's largest hospital-clinic chains (Allina) to form an ACO. This unholy alliance between two 10,000 pound gorillas illustrates a basic fact about "accountable care organizations" -- they are insurance companies. The hospital-clinic chain that wants to pose as an ACO either creates an insurance department in-house, or it contracts out to an insurance company all or most insurance functions (collecting premiums, enrolling "members," administering costly and disparity worsening pay-for-performance schemes, setting aside reserves, dealing with the state's insurance commissioner, etc.). You will see in the article the usual blather about how Allina will now "manage care" and "coordinate care" and "align quality metrics." You will, however, see nothing at all about why empire builders build huge companies via merger and contract -- to create enough market power to maximize what you charge your customers and minimize what you pay your suppliers. What's even scarier is the claim by Allina's CEO that the the covid-19 pandemic is God's way of telling us we must abandon fee-for-service and embrace capitation. The ACO was invented in 2006, and catapulted to the status of federal policy with the enactment of the Affordable Care Act in 2010. All the evidence indicates ACOs are not cutting costs, and may be raising costs if we count the overhead costs ACOs generate. There is some evidence ACOs worsen disparities. Allina cut a deal with Aetna a year or two ago to create a Medicare Advantage plan. Kip == Blue Cross and Blue Shield of Minnesota and Allina Health formed a six-year value-based payment model, the organizations announced Thursday.. The insurer, which covers about a third of Minnesotans, and the 11-hospital system based in Minneapolis aim to reduce costs by 10% over five years by incentivizing more preventative and coordinated care, the organizations said. This would boost doctor-patient relationships, limit administrative expense and ultimately improve outcomes for around 130,000 Blue Cross members who receive care at Allina each year, executives said. The organizations had been planning the payment model for months prior to the COVID-19 pandemic, but it underscored the need for stable, diverse revenue sources and long-term care models that aim to improve individual and community health, said Dr. Penny Wheeler, president and CEO at Allina Health. "If anything, COVID-19 has amplified the need for this type of arrangement," she said, adding that the pandemic not only illustrated the risk of relying predominantly on fee-for-service care but also amplified disparities in care. "We're confident this time is an inflection point." Allina and BCBS Minnesota hope that their agreement can serve as a road map for others exploring similar partnerships, Wheeler said. Both organizations had struggled with the transactional and bureaucratic relationship between payers and providers that often puts patients in the middle, said Dr. Craig Samitt, president and CEO at Blue Cross and Blue Shield of Minnesota. "There's this saying I often refer to: 'An ounce of prevention is worth a pound of cure.' But historically we haven't rewarded the ounce, only the cure," he said. "If we shift the incentives so that payers and providers are rewarded to move care upstream and focus on wellness prevention and the physical and social needs of the community, we should ultimately reduce the cost of care." BCBS Minnesota will pay Allina an upfront sum for certain subsets of patients, and how much Allina ultimately yields depends on how it performs on quality, accessibility and affordability measures, Wheeler said. Allina and BCBS Minnesota plan to leverage their collective data to expand and hone care management services and care coordination as well as establish more affordable and accessible sites for care delivery, like via telehealth. But that is a big lift, requiring accurate projections of who Allina will be taking care of and how to best align quality metrics, sites of care, caregivers and community resources to tackle issues like food insecurity, housing and transportation, Wheeler said. Wheeler noted Allina's cancer care coordination program, which connects newly diagnosed cancer patients to community resources and helps them holistically manage their prognosis by addressing their mind, body and spirit. Although Allina estimates that it saved the community around $1.2 million over a six month span by avoiding nearly 100 hospital admissions, the organization lost $600,000, she said. "There wasn't a sustainable model for that," Wheeler said. "This partnership changes the game completely." Under traditional payment models, acupuncture services for a patient's chronic back pain wouldn't be covered. They would have likely been directed toward surgery, even though that option is often more expensive and less effective, Samitt said. If a patient's bloodwork suggests they were pre-diabetic, a fee-for-service model would jump to medications and clinic visits to treat the disease without treating the cause or focusing on the cure, he said. "This partnership allows us not to just jump to conclusions, but begin with the foundational drivers, which could be nutritional and behavioral, and not just medical," Samitt said. Many providers only dabble in payment models that aren't based on the number of patients seen and services rendered. But COVID-19 has illustrated the tenuous nature of fee-for-service healthcare as non-urgent procedures—often hospitals' and physician practices' primary revenue source—have been incrementally halted amid the pandemic. Those that participate in alternative pay models like capitation, where providers receive a pre-determined monthly amount to care for a group of patients and are on the hook for the cost and quality of care, have been more insulated. This has caused providers to either double down on existing at-risk payment models or explore their options for those that have been reluctant to leave traditional models. "Our hope is that this partnership doesn't just benefit Allina and the patients we both serve, but is a catalyst for the entire community," said Samitt, noting that their partnership is longer than the typical value-based arrangement. "Change is long overdue in this industry."

Tuesday, August 25, 2020

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network

Changes in Hospital Income, Use, and Quality Associated With Private Equity Acquisition | Acute Coronary Syndromes | JAMA Internal Medicine | JAMA Network

Comment by Don McCanne

These private equity investments in health care are designed to increase the value of the assets acquired and then to sell them for a large profit in just a few years. That is, they are designed to make money for the investors - a high profit in a short time span. These equity firms imply that their motivations are altruistic, that they are increasing value, quality, efficiency that makes their products worth the prices that must be paid to net high profits for the investors. So are they really serving the interests of the patients and providers, or are they just simply squeezing funds out of these deals for their own interests?

It appears that they are operating in ways that maximize margin in the near term. That means charging higher prices for the services. It means providing additional services that are of lower value which may actually increase risk to patient safety and health equity. This study showed that "private equity acquisition was associated with increases in annual net income, hospital charges, charge to cost ratios, and case mix index among hospitals." The hospitals acquired by private equity had a decrease in Medicare patients with an increase in privately insured patients which provided higher reimbursements than did Medicare, suggesting that selective marketing efforts were successful in increasing margins. Increases in hospital charges resulted in higher out-of-pocket costs for the uninsured and for those who were receiving care out-of-network. Even in-network insured patients produced higher net incomes since negotiating leverage was greater for the private equity hospitals. After acquisition, "private equity firms began charging more for services, cutting operating costs, or both." After acquisition, the private equity hospitals reportedly saw sicker patients warranting higher charges, but this likely represented more aggressive coding - upcoding just as we see with the private Medicare Advantage plans that result in increases in net income. These private equity-acquired hospitals also supposedly showed greater improvements in process quality measures when, in fact, this actually likely represented gaming in an effort to maximize opportunities for quality bonuses under pay-for-performance contracts.

The medical-industrial complex is more than ripe for equity investors. As if the greed in the system was not already excessive, bringing in the equity investors to squeeze more out of our overpriced and underperforming system is exactly what we should not be doing.

We really do need the single payer model of an improved Medicare for All, but if the stalling by our political leaders in both major parties continues, the economic structure of our health care delivery system will be damaged as with a blunderbuss to the degree that it may be hard to distinguish it from the economic structure of a war zone in need of a Marshall Plan. Really. Private equity acquisition is only one small example of the damage being done throughout the health care economic infrastructure - damage that will be very difficult to repair.

Friday, August 14, 2020

The Potter Report | Tarbell

This week Wendell talks the rigged game of private health insurance.
The Potter Report | Tarbell
“the more prices go up, the more insurers can force their customers to pay in premiums, copays and deductibles.”