About bgleason

Brenda Gleason is a dynamic speaker and facilitator who can help lead your group to bigger picture thinking and creative solutions, especially in the changing health care system.

Giving thanks to…my mentors

By |2019-11-27T18:25:30+00:00November 27th, 2019|Uncategorized|

Giving thanks to…my mentors

As many of us take some time off these next few days to spend time with family or friends, we may also be reflecting on what we are thankful for. Each of us will make a list in our minds, even if we don’t share it “out loud.”

Recently I was asked to be a panelist for the Public Leadership Education Network (PLEN) as part of their annual Women in Health Policy Seminar. The seminar is for college women from across the U.S. considering a career in health policy and helps them learn how to make an impact in the legislative and political processes and how to expand their professional networks.

The panel topic was “Launching your Career” and one of the questions panelists were asked to answer was: “What do you view as a pivotal moment(s) that got you to where you are today in your health career?”

In thinking about my answer I realized there wasn’t really a single “pivotal moment,” but there were lots of “pivotal people” I had the opportunity to learn from and be led by over the years. During the session, I shared a few stories about mentors who had helped me along the way, and advised participants to find their pivotal people to build relationships and get honest feedback.

All of this inspired me to share “out loud” my sincerest thanks to the many mentors I have had who helped me be better than I was the day before. Sometimes it was a word of encouragement. Other times it was help making a difficult decision. Many times it was tough advice and honest feedback about something I was doing that was slowing down my growth. Every time it was a gift. Mentors don’t have to take the time, or make the room, or expend the energy they do. I am immensely grateful for the many pivotal people in my career who have given of themselves to make me better.

Thank you!

Health care costs: What’s the real story?

By |2019-11-13T16:19:34+00:00November 13th, 2019|Health care spending, Health Care Trends, Health Plans, Hospitals, Insurance, Providers, Uncategorized|

Health care costs: What’s the real story?

As I travel around the country talking to state legislators and health care leaders, questions about health care costs are usually at the top of their lists. The first request they make is for credible, public sources of information they can use to help inform their policy decision making.

Two slides I frequently use in presentations receive the highest engagement. My informal measurements of engagement are people in the audience taking pictures of the screen when the slide appears, and comments such as, “This is incredibly helpful” or “I haven’t seen it presented like this before.”

The first slide is a graphic (see below) from the Peterson-Kaiser Health System Tracker and shows how cost-sharing requirements, especially in the form of deductibles, have outpaced wage growth.

The second slide I created because the information is harder to find than you’d expect. Notably, the information is out there, but it is buried in data sets, not in a visual that can be quickly understood and easily shared.

Combining information on health expenditure data and historical inflation information the graphic (see below) shows the annual change in spending for the three most talked about categories of health care, hospitals, physician services, and prescription drugs, as well as general inflation for the last 10 years.

If you live and breathe health policy, these visuals may be no surprise to you. State legislators, on the other hand, are asked to be experts in a mindboggling array of issues. They rely on their staff and the internet to understand these issues, but what if the internet doesn’t serve up the info they need?

M2 aims to be a reliable source of information on all things health policy, and we strive to make complicated information from a multitude of sources more concise and comprehensible. Hopefully, the slides we share prove useful to you. Let us know what you think!

What’s the Reason for the Fall in Health Insurance Premiums? Hint: Not the Market

By |2019-09-05T17:41:07+00:00September 4th, 2019|Uncategorized|

What’s the Reason for the Fall in Health Insurance Premiums? Hint: Not the Market

First published in Morning Consult on August 28, 2019

Several interlinked headlines showed up recently related to annual premiums in state health insurance markets. The Centers for Medicare and Medicaid Services published two reports related to the individual health insurance market, including health plans offered both on and off the Affordable Care Act health insurance exchanges.

While many venues ran with the CMS press release focus on declining enrollment for people who are not eligible for ACA subsidies, the report also showed average total monthly premiums in February 2019 decreased by 1 percent for exchange enrollees.

Charles Gaba, who runs the site ACASignups.net, published a detailed analysis of proposed and approved premiums by state for the 2020 plan year, noting the lowest rate increases ever.

The Heritage Foundation also published a report about these health care premium trends but took it a step further by declaring the purported reason for the declining premiums — “How Health Care Premiums Are Declining in States That Seek Relief from Obamacare’s Mandates.”

Who should pay for risk?

Insurance, by definition, is about managing risk. A person or entity pays a small amount to hedge against the risk of having to pay a much larger amount. Insurance companies make their money by being good at predicting risk. In the case of health care, health insurers charge a premium to a pool of people and anticipate that the amount of premiums received in a given year (plus some amount of reserves) will be enough to cover the costs of the health care needs of that population in that particular year.

But what happens if the insurance company can offload some of that risk? If the health insurance company doesn’t have to pay for some of the costs for its covered population, then it can reduce the premiums it charges. Reducing the impact of high claim amounts from a small portion of the covered population — for example, the one person who is diagnosed with a rare cancer — can be accomplished by allowing another entity to pay for those claims.

In many other types of insurance, companies step in to take on that extra risk and sell “reinsurance” policies. So who is paying for the risk in state health insurance markets?

State-based reinsurance backed by the federal government

Section 1332 waivers were established by the ACA to enable states to waive provisions related to the individual and employer mandates, premium credits, cost-sharing reductions, benefits, qualified health plan requirements, etc. To date, 13 Section 1332 waiver applications have been approved by CMS, and all but one (Hawaii) concerned state implementation of reinsurance programs. One additional 1332 waiver is pending, but does not implement reinsurance (Idaho).

Although CMS issued new guidance in October 2018 on Section 1332 “State Innovation Waivers,” changing the name to “State Relief and Empowerment Waivers,” nearly all of the 1332 waivers so far have allowed insurers to stop doing what insurers do and instead have the federal government do it.

Colorado, which had its 1332 waiver approved in July, explained the concept clearly:

The … waiver would reduce premiums through the introduction of a state-based reinsurance program starting in 2020. This program, established by the state, would pay for a portion of claims for high cost members in the non-group ACA-compliant health insurance market. … The reinsurance program would pay a percentage of claims, above the attachment point and up to a cap. Covered claims would reduce the total costs paid by carriers in the non-group market. Therefore, any reductions to claims costs due to reinsurance would reduce premiums as well.

The “attachment point” is the floor. The responsibility for paying the health care claims of that amount or more will be shared by the health insurance company and the government. The “cap” is the ceiling. Health care claims up the amount of the cap will be shared.

In the case of Colorado, the range between the attachment point and the cap is $30,000 and $400,000. Reductions to claims costs for insurers most likely mean lower premiums.

Risk stabilization courtesy of the federal government

While the Heritage Foundation report claims premiums are decreasing because some states have sought “relief from Obamacare’s mandates,” the real reason is because insurers are being allowed to shift the costs of high claims to the state and federal government. The report goes on to say, “the study finds that premiums declined significantly in the … states that obtained federal waivers to operate risk-stabilization programs.”

Heritage is right that premiums are down in states that asked for 1332 waivers related to reinsurance. But risk stabilization courtesy of the federal government is hardly a market-based solution to rising health care costs. Medicare for All proponents, take note.

Can Price Transparency in Health Care Really Lower Costs?

By |2019-08-21T14:53:39+00:00August 20th, 2019|Health care spending, Health Care Trends, Hospitals, Insurance, Out-of-pocket spending, Physician-patient communication, Providers, Reimbursement, Uncategorized|

Can Price Transparency in Health Care Really Lower Costs?

Telling patients what they will pay for their health care services is a key stepping stone to more efficient use of health care dollars. Consumers, employers, payers, and the system as a whole would likely benefit if the true cost to the patient were made available before a patient receives a health care service or product.

Several states already have laws on the books requiring health care providers to make at least some price information available on at least some procedures. Some states also run centralized databases where different payers report what they get paid for different services. Additionally, the federal government requires hospitals to post a list of standard charges on the internet.

The Trump Administration wants providers to further expand the price and quality information to consumers, and issued an Executive Order (EO) on Improving Price and Quality Transparency in American Healthcare to Put Patients First in late June. The order aims to help consumers make “well-informed decisions” and expand transparency efforts that provide information “which patients can research and compare before making informed choices based on price and quality.”

More specifically, the EO directs the U.S. Department of Health and Human Services (HHS) to require hospitals to publish negotiated rates in a searchable, consumer-friendly format for 300 “shoppable” services.

You Can Shop if You Want To

Consumers are being asked to make more of these decisions on their own, as we’ve described in previous posts. My home state of Colorado has a shopping tool like the one the EO has in mind. It took me less than a minute to get the result below from the Colorado Center for Improving Value in Health Care (CIVHC) for an MRI scan of a leg joint within 15 miles of my ZIP code:

Shop for Health Care Services – MRI Scan, Leg joint (CPT 73721)

Seems pretty obvious that while the closest option, seven miles away, is Centura Health St Anthony Hospital, they would charge me $510 for the scan. If I drive another five miles, I would only have to pay $150 at Denver Health Medical Center.

“Shoppable,” but Perhaps Not “Buyable”

According to the Health Care Cost Institute (HCCI), “For a health care service to be ‘shoppable’, it must be a common health care service that can be researched (“shopped”) in advance; multiple providers of that service must be available in a market (i.e., competition); and sufficient data about the prices and quality of services must be available.” HCCI estimates that approximately half of out-of-pocket spending is spent on “shoppable ambulatory doctor services.”

The problem is, you might be able to research and compare certain services with upgraded information, thus improving your shopping experience, but you might really struggle to buy the service that is lower in cost.

Using the example of lower-limb MRIs, a 2018 study titled Are Health Care Services Shoppable? Evidence from the Consumption of Lower-Limb MRI Scans found that people typically drive by multiple lower-priced providers to get to their final treatment location. Why? Because that is where the patient’s referring provider sends them. The study shows “the influence of referring physicians is dramatically greater than the influence of patient cost-sharing or patients’ home ZIP code fixed effects.”

In particular, “physicians who are vertically integrated with hospitals are more likely to refer patients to hospitals for lower-limb MRI scans.” We’ve written previously about how costs vary dramatically by site of care. That also means patient cost-sharing varies. We are asked to pay more out-of-pocket for a service we could get elsewhere. But that would mean 1) shopping and 2) acting against the advice of a provider. Not impossible tasks, but difficult for sure.

Increased transparency means you can shop for services, but that is only half of the problem. Yes, it is important to have price and quality information. If the problem were a technical one, more information would lead to different decision making. But in fact, changing the way a consumer selects a health care service – even a “shoppable” service – is an adaptive problem. That is, it requires a change in the way people think, prioritize, and behave.

Additional information on quality and price is definitely necessary, but if I drive by two Centura Health facilities with lower cost MRIs to get to the HealthOne facility my referring provider recommended, I would also need some encouragement, at least, to go against my physician’s recommendation.

It looks like we health policy types have more work to do.

Have we passed peak health care disruption?

By |2019-07-08T21:03:06+00:00July 8th, 2019|Health Care Trends, Health Reform, Innovation, Uncategorized|

Have we passed peak health care disruption?

Disrupting health care has been a hot topic the past few years, but it seems to me we have passed peak health care disruption and firms are now having to roll up their sleeves to do the boring, difficult work of creating incremental change.

The high point of disruption in health care (see chart below) looks to be the announcement January 30, 2018 from Amazon, Berkshire Hathaway, and JPMorgan Chase & Co. of a health care joint venture to “address healthcare for their U.S. employees.

What has happened related to that partnership in the last 18 months is the naming of the entity (Haven), some prominent hires (Dr. Atul Gawande), and some key staff departures (Jack Stoddard).

But there have been some notable smaller steps from two of the three Haven entities that signal feasibility and immediate impact are stronger drivers than disruption. While policy types may be interested in wholesale transformation, the business of digital health is concentrated on more immediate change.

Right after the Haven announcement, Amazon bought PillPack, an online pharmacy and platform that helps manage patient data. Last month, JPMorgan Chase & Co. bought InstaMed, adding health care payment services to the bank’s existing service offerings in wholesale payments. Knowing more about your customer and serving them better, just like in any other business, seems to be where health care companies are focused.

These kinds of digital health deals may be the wave of the future, according to RockHealth’s 2019 Midyear Digital Health Market Update. Their report (see chart below) shows a steady amount of digital health investing year-over-year, but an increasing average deal amount.

Perhaps more importantly, acquisition by non-health care companies is proving to be an increasingly likely exit ramp for digital health investors, as the PillPack and InstaMed deals exemplify. Providers and non-health care companies are stepping up their acquisitions of digital health ventures, as the chart below shows.

The next step in health care might be smaller than the word “disruption” implies. Over the past few years, health care has proven to be more complex than many tech companies and policymakers have thought. RockHealth quotes David Kim, Managing Director of DigiTx Partners, as saying: Big tech companies “are likely to acquire technologies and companies with expertise and domain knowledge that allow them to take that next step to health care without just diving in blindly headfirst.”

If disruption equates to diving in blindly headfirst, I agree. Health care change going forward is going to be data-fixated, consumer-focused, and incremental.

On the 50th Anniversary of the Stonewall Uprising, A Simple Message

By |2019-07-08T21:00:21+00:00June 28th, 2019|Uncategorized|

On the 50th Anniversary of the Stonewall Uprising, A Simple Message

The President of Russia, Vladimir Putin, just made international news by saying, “Liberalism has become obsolete,” and the liberal order has pursued mindless multiculturalism. To the young people I know who think the fight is over, I gently remind them, history is a circle not a line.

And to those who have gone before me to live their lives as LBGTQ people, as well as to those who have fought, and continue to fight for us, in ways large and small, I would like to send a heartfelt thanks.

I couldn’t have done it without you, and I will honor your memory by continuing the fight.

Robert Pear taught me how to listen and I am forever grateful

By |2019-05-17T15:09:29+00:00May 16th, 2019|Uncategorized|

Robert Pear taught me how to listen and I am forever grateful

Last week, one of my health care heroes passed away. Robert Pear, health care reporter for the New York Times, died on May 8, 2019, RIP. If you know nothing about this incredible reporter, these articles in the New York Times Robert Pear, Authoritative Times Reporter on Health Care, Dies at 69, and Washington Post, Robert Pear, Scrupulous Chronicler of Health Care for the New York Times, Dies at 69, are useful starting points.

Not many people know that while I started working in health care in Massachusetts at the Department of Health, I then moved to D.C. and was a “cub reporter” with real press credentials. As I learned the health care beat, working for a newsletter company called CD Publications, I also came to know of Robert Pear.

My first D.C.-based reporting job was to churn out a newsletter every two weeks called the Community Health Funding Report. Eventually I became the Supervising Editor of the AIDS/STD News Report, Mental Health News Alert, and Substance Abuse Funding News newsletters. While each of these newsletters covered some “real news” about what was happening in D.C. related to their respective health care topics, each publication was truly only serving its readers if it provided information on newly announced grants or contracts.

This was way back in the mid-1990s (!!) so I had to go in-person to press conferences, meetings, Hill offices, briefings, etc. in order to figure out what was happening. One of my first interactions with Robert Pear was after a Hill briefing on some health care issue I was just learning. As the briefing ended, the HHS representatives who participated were moved to the back of the room. Before they could even grab their coats, Robert was in front of them:

“Robert Pear. New York Times,” he announced before starting his question.

First lesson learned: Don’t wait for the perfect moment to approach someone, just do it!

Second lesson learned: Say your name and publication before asking your question. It wasn’t until quite a bit later that I realized when you say “Robert Pear. New York Times,” it is just a formality because pretty much everyone in the health care policy world knows who you are, and when you say, “Brenda Gleason. Community Health Funding Report” you might have to say it several times. It probably wouldn’t matter anyway, because I also learned the person being asked might only answer one question and it would be Robert’s, not mine.

So I leaned in and tried to learn.

When Robert Pear asked a question, he didn’t ask about what the person had just said during the hearing or meeting. He would ask a question that did something totally different. He would weave together several pieces of information from many different sources that he had read, or heard, or something that had been speculated about, and he would ask his question. Robert Pear’s question-asking was impressive. But what was truly amazing was how he listened. The New York Times obituary said, “Colleagues described him as an almost sphinxlike good listener.”

Third lesson learned: Great questions come from listening.

I learned to listen, really and truly, deeply listen, from Robert Pear. I also learned the importance of weaving together all kinds of information from different places to read between the lines, anticipate what might happen next, ask great questions, then after more listening, connect the dots.

The one occasion in which I was able to help Mr. Pear is “on-the-record” and I still find it thrilling:

President Wants Curb on Medicaid, January 14, 1997

“Over the objections of senior members of his own party, President Clinton is drafting a budget that would set firm limits on Federal Medicaid spending as a way to help balance the Federal budget by 2002.”

“A newsletter that follows Federal spending for public health said today that Mr. Clinton would seek additional money for treating people with AIDS, for Head Start and for the Indian Health Service. But the newsletter, Community Health Funding Report…”

To Robert Pear I am forever grateful for teaching me so much. May he rest in peace.

“Medicare-for-All” Understood as Lower Premiums for Me?

By |2019-05-07T20:39:01+00:00May 7th, 2019|Health care spending, Health Care Trends, Health Plans, Health Reform, Insurance, Medicare, Medicare For All, Out-of-pocket spending, Uncategorized|

“Medicare-for-All” Understood as Lower Premiums for Me?

Proposals for Medicare-for-All, or more accurately, universal health coverage, are being introduced by both Congress and state legislatures at a rapid pace (see this useful interactive tool, The Many Varieties of Universal Coverage from The Commonwealth Fund). While policy types argue over how such a plan would be funded and how to set reimbursement rates for providers, and Wall Street frets about what single payer health coverage would do to health insurance companies, state legislators and regular people seem to have a different perspective. In my many conversations with people across the country about the idea of “Medicare-for-All,” I have found it striking how often people say they favor such an approach because they want lower health insurance premiums.

I think we may have a language problem. When health policy people hear “Medicare-for-All”, they think “change the health care delivery and insurance infrastructure from employer contributions to taxpayer contributions,” but maybe when regular people say “Medicare-for-All”, they mean “please find a way to lower my premiums”. The Kaiser Family Foundation Health Tracking Poll conducted in early January hints at the importance of lower premiums as a reason to support “Medicare-for-All” type proposals. As shown in the figure below, nearly 50% of people polled strongly favored proposals that allow people between 50 and 64 years of age to buy in to Medicare, or allow people to buy in to Medicaid, or create a plan like Medicare that is available to anyone. Getting insurance from a single government plan is strongly favored by only 34% of respondents.

These “buy-in” proposals may be gaining in popularity as people lose access to employer-sponsored insurance. Here is the math: “if the coverage rate for employer-sponsored insurance was the same in 2017 as it was in 1999 (67.3%), almost 24 million (or 23.8 million) additional people would be covered through an employer plan in 2017.”

It’s easy to understand why people would focus on lower health care premiums; rising premiums are having a big impact on household incomes. As fewer people are receiving health insurance through their employer, they are also being exposed to higher costs for health care premiums. We pulled recent information on employer and worker contributions for health insurance, the average national premium for a person earning just over 400% of FPL ($49,000) to buy a health plan on the ACA Exchange at various ages, and Medicare premiums. We then created a rough comparison chart of what premiums an individual might have to pay for health insurance based on how they accessed coverage. Below is what we found:

Notably, the average annual premium for employer-sponsored coverage of an individual was about $6,900 last year. But employees usually paid just 18% of that amount. For people who may have been covered by their employer for years, and then have to buy insurance in the ACA Exchange, the loss of that employer-sponsored contribution to their health insurance coverage could be quite a shock.

It’s a catchy phrase and easy to hashtag in social media, but is the appeal of Medicare-for-All driven largely by the hope that a person’s premiums will be lower? Is Medicare-for-All the best or only way to achieve lower premiums? As with all policy issues, we should probably start with the key question, “what problem are we trying to solve” and then go from there, always checking to see that we are, in fact, addressing the problem we are trying to solve with a workable solution.

Same health care, different setting, but much higher costs

By |2019-04-25T20:36:11+00:00April 24th, 2019|Health care spending, Health Reform, Insurance, Medicare, Uncategorized, What do we pay for and why|

Same health care, different setting, but much higher costs

There is so much health care news happening right now, you may not have seen this, but different services cost different amounts, depending on where they were delivered. While this concept isn’t necessarily news to health care policy types, this latest data set and accompanying graphics make the issue clearer than ever and beg for a policy fix.

The Centers for Medicare & Medicaid Services (CMS) finalized the Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs Rule November 21, 2018, implementing site neutral payments for hospital outpatient clinic visits. The policy essentially reduces payments for services provided in outpatient settings to the same level as the payment made for the same service in a physician’s office.

However, the policy change applies only to Medicare, which covers less than 20% of the U.S. population. The commercially insured, for example, via employer-sponsored insurance and the individual and small group market, account for 56% of the population (see Charles Gaba, The Psychedelic Donut: Types of Coverage in the U.S.).

Wouldn’t a similar policy for people who receive health insurance outside of Medicare be a way to reduce costs?

Outpatient setting is always more expensive…

The Health Care Cost Institute compared a common set of services performed in physician’s offices and outpatient hospital settings and found “for this set of services, the average price was always higher in an outpatient setting than an office setting.”

Services that saw a significant change when provided in an office vs. an outpatient setting varied by service. Some of the bigger changes were for ultrasounds, upper airway endoscopies, and drug administration. For example, “in 2017, 45.9% of level 5 drug administration visits occurred in outpatient settings, compared to 23.4% in 2009.”

Not only did prices increase over time for both settings, the site differential for some of the visits was stunning.

We took the HCCI info and added a calculation of our own for a few of the visit types to show the percentage difference between the price of a visit in the office setting vs. outpatient setting, as shown in the table below.

It is also something that should be made transparent to patients. As mentioned in a recent blog, health care costs are rising and people are struggling to afford those costs. States are passing transparency bills left and right (hospital transparency, drug price transparency), even though it is unclear how “transparency” actually lowers costs. However, implementing site neutral payments for all payers (not just Medicare) is a more obvious, and more immediate, improvement to rising health care costs.

Even Employed People with Health Insurance are Worried about Health Care Costs

By |2019-04-17T20:59:33+00:00April 17th, 2019|Health care spending, Health Plans, Insurance, Out-of-pocket spending, Uncategorized|

Even Employed People with Health Insurance are Worried about Health Care Costs

Gallup published survey results in April showing health care was American’s top concern. According to the poll, 55% of Americans worried “a great deal” about “the availability and affordability of health care,” and another 25% worried a “fair amount.” Notably, only 23% worried a great deal about unemployment and 33% worried about the economy in general.

Keep in mind when Gallup asked the same questions in 2011 and 2012, 71% of people worried “a great deal” about the economy, but about the same percentage worried about health care costs a great deal as are worried today.

This implies people are feeling flush and have jobs, but still worried about affording health care. Why is that?

In part this is because across roughly the same time period, both health insurance premiums and deductibles have risen, even for people with employer-sponsored insurance (ESI). A study by the University of Pennsylvania Leonard Davis Institute of Health Economics and the United States of Care, also published in April, found that between 2010 and 2016 incomes only grew by about 20%, but premiums grew by approximately 30%, and deductibles grew by more than 55%, nationally. The study provides a state-by-state breakdown but the graphics below give a snapshot of how premiums and deductibles have jumped.

It is no wonder then, that in another Gallup survey released this month, participants said, “Given the choice between a 10% increase in income or a complete five year freeze of health care costs, 61% of people said they’d choose the latter.”

At both the federal and state levels, policymakers are being asked by constituents to come up with ways to make health care more affordable. While some might hear the phrase health care costs and think hospitals or prescription drugs, these survey results and state-by-state data show the cost of health insurance – even for those receiving coverage through their employer – is becoming unmanageable.

When the people who everyone thinks have the “best coverage” are complaining about that coverage, we would do well to broaden the debate. Policy solutions need to focus on the cost of health insurance in order to address people’s concerns. Elected officials, are you listening?