Uncategorized

Health Care Reform Has States and Feds in Tug-of-War

By M2|2017-10-11T23:46:10+00:00October 11th, 2017|Health Reform, Uncategorized|

Health Care Reform Has States and Feds in Tug-of-War

In the past nine months, the Republican-controlled Congress have failed a couple of times to make significant changes to the Affordable Care Act (ACA) through legislation. As state policy people, we watch closely what happens in states, and right now we are paying extra close attention, because the health care financing and delivery system needs changes regardless of what Congress can achieve.

Last month, the U.S. Senate Committee on Health, Education, Labor & Pensions (HELP), led by Lamar Alexander (R-TN) and Ranking Member Patty Murray (D-WA), held full committee hearings on Stabilizing Premiums and Helping Individuals in the Individual Insurance Market for 2018 in September. The committee hosted five Insurance Commissioners on September 6, 2017, and five Governors on September 7, 2017. M2 watched the hearings for clues about what states are most interested in focusing on when it comes to health reform, and what kind of support they need from the feds in order to pursue changes.

Insurance Commissioners Testifying

Five Insurance Commissioners provided testimony to the Senate HELP Committee:

AK: Lori K. Wing-Heier, Director, Alaska Division of Insurance
OK: John Doak, Commissioner, Oklahoma Department of Insurance
PA: Teresa Miller, JD, Insurance Commissioner of Pennsylvania
TN: Julie Mix McPeak, Commissioner, Tennessee Department of Commerce & Insurance
WA: Mike Kreidler, Washington State Insurance Commissioner

Governors Testifying

Five Governors provided testimony to the Senate HELP Committee:

CO: John W. Hickenlooper, Governor, Colorado (D)
MA: Charlie Baker, Governor, Massachusetts (R)
MT: Steve Bullock, Governor, Montana (D)
TN: Bill Haslam, Governor, Tennessee (R)
UT: Gary Herbert, Governor, Utah (R)

Key Themes from Insurance Commissioners’ and Governors’ Comments

Each of the Governors and Insurance Commissioners provided short testimonies, then each panel fielded questions from various members of the committee. As with many of these public events, there is a fair amount of posturing that happens. Looking past the posturing, several key themes emerged from the panel members. The Insurance Commissioners and Governors said:

Congress should fund the cost-sharing reduction (CSR) payments in order to stabilize the individual health insurance markets in the states.
The federal government should fund some sort of reinsurance program, at least for a short period of time until states can take over the function.
The Centers for Medicare & Medicaid Services (CMS) should provide states with increased flexibility and responsiveness to 1115 Medicaid waiver and 1332 State Innovation waiver requests such as:
- Faster approval times (shorten timelines to complete in 90 days);
- Flexibility in budget neutrality provisions;
- Simplify the process;
- Expand the list of what can be waived;
- Let more consumers buy catastrophic plans.
Bringing down health insurance premiums will require addressing the underlying drivers of health care costs.
Six of ten testimonies mentioned the cost of prescription drugs.

Many of these ideas are not exactly new and have been requested by both states and associations before. For example, take a look at the responses from states in January 2017 to a request for comments on health insurance markets and Medicaid from House Majority Leader, Kevin McCarthy (R-CA), as well as ideas that have been put forth by the National Governors Association Shared Priorities from the Governors’ Bipartisan Health Reform Learning Network. 13 states participated in the Learning Network (California, Delaware, Kentucky, Minnesota, Montana, Pennsylvania, South Dakota, Tennessee, Utah, Vermont, Virginia, Washington, and Wyoming, a mix of Rs and Ds) and recommended “Stabilization of the Private Health Insurance Market,” including the federal government fully funding the cost-sharing reductions (CSRs) and providing at least short-term funding for reinsurance (sound familiar?). The Learning Network also asked for increased state authority and flexibility to act in health insurance markets, Medicaid, payment and delivery system reform, and public health priorities, including addressing the opioid epidemic.

Of particular note, many of these comments from state officials are starting to emphasize the need not just to address the cost of insurance, but to go deeper and find ways to address the cost of health care. Trying to get people to be more healthy, and trying to get providers to accept payment for health outcomes are also not new ideas, but so many state officials talking about them as part of a state’s responsibility to her residents is a bit unique.

What happens next is likely to happen in the states, even as the Feds seem to be sending mixed messages about approving waivers for flexibility – see Iowa, Minnesota and Oklahoma news from the past few weeks for examples. We know what states want. What will they get? Stay tuned!

Is there anything about “SINGLE” we could like?

By M2|2017-10-08T11:15:04+00:00October 4th, 2017|Health care spending, Health Care Trends, Health Information Technology, Health Reform, Uncategorized|

Is there anything about “SINGLE” we could like?

As I write this, the latest version of Republican health reform has been halted. The Graham-Cassidy-Heller-Johnson bill (H.R.1628) was officially declared dead and next steps are all guesstimates.

It might be a coincidence that the bill was pulled and Senate Republican leadership decided not to bring the bill the floor for a vote just a day after CNN broadcast a debate between Sen. Bernie Sanders (D-VT), Sen. Amy Klobuchar (D-MN), Sen. Lindsay Graham (R-SC), and Sen. Bill Cassidy (R-LA) on “Obamacare”, CNN Debate Night: The Fight Over Obamacare; and a week after Sen. Sanders introduced the so-called “Medicare for All” bill on September 13.

More than once the CNN debate devolved into an argument over the Graham-Cassidy bill vs. “single payer” health care. But notably, two audience questions (one from a Republican and one from a Democrat) asked the Senate debaters to say what they would do immediately to lower the cost of premiums.

Usually the word “single” in health policy circles makes people think of “single payer.” In my opinion, there is not much possibility with the current Congress to pass a “single payer” bill that would create a nationalized health insurance and health provider system, but I do wonder if there is anything about the concept of “single” that could become policy. Here are two ideas: 1) A “single set of forms” and 2) A “single health IT system.”

“Single Set of Forms”

First, a single set of forms. Could Congress agree to pass a law that would require all insurers, payers, pharmacy benefit managers, etc. to use a standardized set of forms for everything from enrolling in a plan, to requesting a prior authorization for a prescription or medical procedure, to receiving a bill?

The concept isn’t new. Administrative simplification has been a buzzword off and on for more than a decade. Savings from reducing “billing and insurance-related” costs are substantial. A study in 2014 estimated, “A simplified financing system in the U.S. could result in cost savings exceeding $350 billion annually, nearly 15% of health care spending.”

Other studies have attempted to quantify exactly how health care providers waste administrative resources because of the multiple systems they must navigate in order to serve patients. For example, a typical physician might spend 3 to 4 hours per week interacting with health plans, other health care staff (e.g., RN/MA/LPN etc.) might spend 3 to 4 hours per physician per day, and clerical staff might spend 6 to 7 hours per physician per day interacting with health plans. Of the administrative activities involved, the majority of time spent is getting authorizations from health plans to perform services and navigating drug formularies.

A stark and oft-cited example is the Duke University hospital system that has three hospitals with 957 beds, but 1,600 billing clerks. Hard to think that a single set of forms – even if you have multiple payers – wouldn’t be a great way to save money in the U.S. health care system. Seems like “single” when it comes to “single set of forms” is an idea many people could support.

“Single” Health IT System

Second, a “single” health information technology (HIT) system might be a kind of “single” we could like in health care. Recently, the longtime CEO and president of the world-class health care delivery system Cleveland Clinic, Dr. Toby Cosgrove, appeared on Meet the Press Daily to discuss the Graham-Cassidy bill. Most of his comments were focused on ways to improve the current health care system, and one of his top ideas was to make health IT systems interoperable. He would certainly know.

A study from WestHealth Institute in 2013, The Value of Medical Device Interoperability, estimated more than $30 billion could be saved annually by making medical devices “talk to each other.” This seems obvious but the graphic below from WestHealth shows what is typical HIT in a hospital.

Sharing information from one device to another or between devices and the electronic health record (EHR) in a “consistent, predictable and reliable way” that allows clinicians to act upon the information would not only save money, it would also save lives and reduce negative outcomes. Lack of interoperability causes adverse events such as drug errors and diagnostics errors. Keep in mind that about 250,000 people die every year from medical errors. It also impedes clinicians’ abilities to prevent events such as pneumonia caused by ventilators put in at the hospital or postoperative shock.

Why does the word “single” in health care carry such negative connotations? Maybe because most parties—consumers, doctors, hospitals, and plans—don’t think a one-size-fits-all approach will work in this country to address such a wide set of needs when it comes to health care. But the downside to this stigmatization is that the word “single” has become so politically loaded that just uttering the phrase is often enough to stop a conversation that might otherwise turn into useful ideas for reforming our current health care system.

Maybe it’s time to focus on some good ideas for the word “single”—ideas that would truly benefit our large and diverse country. Administrative simplification and interoperability seem like a good place to start.

Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

By M2|2017-10-08T11:16:59+00:00September 28th, 2017|Chronic pain, Evidence-Based Medicine, Health Disparities, Uncategorized|

Quality of Treatment for Migraine Doesn’t Seem To Differ By Race, But Opioid Prescribing for Migraines is Still Too High

Headaches are one of the main reasons patients seek health care advice, and racial and ethnic differences exist. For example, migraine in African Americans is more frequent, more severe, more likely to become chronic, and associated with more depression and lower quality of life versus non-Hispanic whites. Given these disparities, researchers at the University of Michigan set out to determine whether there are also racial differences in the quality of migraine treatment.

In a study published in Cephalalgia, researchers reported that approximately 40% of patients received no preventive medications – prophylactic treatments – though that is the recommended approach for most patients. Further, “among patients that receive a prophylactic agent, it is almost twice as likely that they will receive exclusively agents with low-quality evidence as it is that they will receive agents with only high-quality evidence.”

As for race or ethnic differences in prophylactic treatment, however, patients were treated similarly: 41.3% of African Americans (AA) received no prophylactic treatments from 2006 to 2013, compared to 40.8% of non-Hispanic whites (NHW), and 41.2% of Hispanic (HI) patients.

For patients who needed first-line treatment (also called “abortive treatment”), as with preventive medication, the University of Michigan researchers did not find relevant differences across ethnicities or races, but they did find nearly 40% of patients did not receive a first-line treatment when it was indicated. And similar to the prescribing pattern for preventive medications, when a first-line treatment was prescribed, it was more likely to be one with low-quality evidence.

“This shows an underuse of medications with high-quality evidence,” first author Larry Charleston IV, M.D., M.Sc., an assistant professor of neurology at the University of Michigan Medical School said. “Even for patients being prescribed an abortive medication, we found 27 percent of them were given at least one low-quality abortive medication. Better options do exist.”

The data “suggest that there are major opportunities to improve the quality of headache medication prescribing in the United States, as less than a quarter of migraine patients received all high-quality abortive or prophylactic medications.”

Perhaps most disturbingly, migraine patients “receive prescriptions for opioids about as commonly as they receive prescriptions for medications with high-quality evidence for migraine treatment,” the researchers found.

Looking at the use of opiates, 15.2% of all patients had a prescription for opiates, but there were no racial differences, Larry Charleston and James Burke, University of Michigan, say. In other words, the “investigation into racial disparities in migraine treatment came up empty, but instead it found a different concern that reaches across populations” – opioid overuse, as noted in an article in Lab Report.

The findings on opioid overuse come at a time when opiate-related mortality is “rapidly increasing in the United States,” the study authors note.

“The argument against opiate use for migraine is strengthened by the observation that it is associated with more severe headache-related disability, symptomology, comorbidities (depression, anxiety, and cardiovascular disease and events), greater need to see health care providers and high risk for medication overuse headache. Moreover, most evidence suggests that opiates are, if anything, less effective than non-opiate alternatives,” according to the researchers.

“Given the considerable risks of opiates and the lack of evidence of increased efficacy, opiates should be used rarely, if ever, for migraine,” they conclude. “Interventions to reduce opiate use in the migraine population are urgently needed.”

This overuse of opiates and underuse of less risky, more effective therapies is another example of practitioners ignoring evidence-based medicine. What’s different about this particular example is that it involves opioids, at a time when the opioid abuse crisis has become so critical that the President recently declared it a national emergency. This seems to be an area ripe for educating physicians or for health plans to provide appropriate parameters for prescribing of migraine therapies, to ensure opioids are prescribed only for patients who truly need them.

Spending More, but Getting Less: How Hospitals Can Work Together to Reap the Benefits of Increased Spending on New Technologies

By M2|2017-10-08T11:20:04+00:00September 25th, 2017|Health Information Technology, Uncategorized|

Spending More, but Getting Less: How Hospitals Can Work Together to Reap the Benefits of Increased Spending on New Technologies

Hospitals often buy new technologies without requiring that the technologies communicate with each other, even though this lack of interoperability results in lower physician productivity and an increased likelihood of medical errors occurring. Other hospitals, fearing exactly those inefficiencies, simply avoid buying innovative new technologies. Peter Pronovost and his colleagues at Johns Hopkins Medicine, give some advice on how to avoid these issues in “What Hospitals Can Learn from Airlines About Buying Equipment,” in the Harvard Business Review.

Hospitals’ spending on new technology “has ballooned,” the authors note. “For years, hospitals have invested in sophisticated devices and IT systems that, on their own, can be awe-inspiring,” the authors say. “Yet these technologies rarely share data, let alone leverage it to support better clinical care.”

“Part of the solution must involve hospitals,” the authors state. “If they truly want technologies that save lives and boost productivity, they will need to exert their considerable pressure as purchasers, requiring that manufacturers embrace openness and interoperability, and only purchasing devices that support this.”

“Too often, hospitals treat equipment and IT procurement in a siloed way, focusing on price without looking at how those devices will work as part of a larger system,” the authors say.

“For example, many new hospital beds come with a sophisticated array of sensors that can track such information as whether a patient is at risk of developing a bedsore, based on data about how often they move in bed. Such sensors may be 30% of a bed’s costs. Yet at one of our hospitals [within the Johns Hopkins system], that data is unusable — it’s in a format that our system cannot read.”

The situation is similar for “much of the data that is fed from wireless monitors of patients’ heart rate, blood oxygen levels, blood pressure, and breathing rate: This data doesn’t link to the medical record,” they note.

“The vision of an integrated hospital unit that is much safer and more productive will not be possible without widespread availability of products that share data openly and freely. Just as the U.S. Navy demands that its submarines and ships have interoperable technologies, this change can be driven by those who purchase these technologies,” they say. “Health care leaders that purchase technologies need to do the same.”

However, it is “unrealistic to think that each hospital should go it alone, exerting its purchasing power to move the marketplace,” the article states. “Hospitals could work together, writing specifications and functional requirements for the products that they will purchase and refusing to do business with manufacturers that don’t comply.” There may also be a role here for group purchasing organizations, they say.

As a further step, instead of assembling hospital rooms “one product at a time, hospitals should be able to purchase modules, sets of interoperable products that work together to support an aspect of care,” the authors continue. “This model makes sense, as few if any hospitals have the resources to design and manage all the connections between technologies, or to optimize how the data is used and displayed to support top-quality care. Ultimately, when a hospital is built or renovated, it would have the option to buy modular patient rooms, clinical units or floors — a ‘hospital in a box,’ built to its specifications.”

“We don’t expect airlines to build their own planes. They buy them from experienced system integrators such as Boeing or Airbus,” and hospitals should have a similar model, the authors note. “The question is whether health care leaders will have the resolve to require it.”

On the other hand, “even if digital devices communicate with one another, the lack of standards for health data puts full interoperability and data sharing out of reach,” according to an article in Healthcare Dive highlighting the opinion piece. “While we’ve made progress in the last three to four years and have the promise of FHIR (fast healthcare interoperability resources), the standards in health care from a data exchange standpoint are very weak,” explains Paul Shenenberger, CIO of Summit Health Management.

The lack of interoperability and data standards will be especially challenging as access to health care continues to change in the digital age, as a separate Healthcare Dive article points out. “From alternative care settings to telehealth companies, supply and demand for healthcare services is in flux.”

“Care is actually moving away from the hospitals,” the article quotes Dr. Rasu Shrestha, Chief Innovation Officer at UPMC, as saying during a panel at the National Health Policy Conference (NHPC) earlier this year. “’The brick and mortar hospitals that we know today will not be the focal point of healthcare delivery tomorrow.’ As care moves away from hospitals, whether at large or in part, it will be important to integrate health data from all over the care spectrum to get a full picture of a person’s well-being.”

This points to the persistent challenge related to use of new technologies in health care; in a siloed, non-standardized data world, how do we leverage the massive amounts of data generated in health care every day and facilitate data sharing in a way that actually makes health care more efficient and effective? The Hopkins op-ed authors take a step in the right direction – urging hospitals to leverage their significant purchasing power to demand interoperability. However, in order to do that, the data standards challenges will also need to be resolved. As Healthcare Dive summarizes, “though it may be a painful process, the need for standards and interoperability are desperately needed for innovative care to move forward.”

Balance Billing: California Latest State to Protect Patients Against Surprise Bills From Out-of-Network Providers

By M2|2017-10-08T11:21:23+00:00September 19th, 2017|Hospitals, Insurance, Uncategorized|

Balance Billing: California Latest State to Protect Patients Against Surprise Bills From Out-of-Network Providers

As of this summer, California is joining other states that have consumer protection laws prohibiting balance billing. Balance billing – also known as surprise medical bills – refers to the practice of billing patients for out-of-network providers even when the care was given in an in-network facility.

“Here’s a common scenario: A patient takes pains to ensure her hospital and surgeon are in-network, only to get billed by the out-of-network anesthesiologist who appears at her bedside to put her under,” according to a recent article by Kaiser Health News published in Healthcare Finance.

“This situation could arise in an emergency when the patient has no ability to select the emergency room, treating physicians, or ambulance providers,” the Kaiser Family Foundation says. “Surprise medical bills might also arise when a patient receives planned care from an in-network provider (often, a hospital or ambulatory care facility), but other treating providers brought in to participate in the patient’s care are not in the same network.”

“These can include anesthesiologists, radiologists, pathologists, surgical assistants, and others. In some cases, entire departments within an in-network facility may be operated by subcontractors who don’t participate in the same network,” the foundation notes.

A total of 21 states now have laws protecting consumers against balance billing. A brief by The Commonwealth Fund classify the laws as partial or comprehensive protections (see map below). Six states are considered to have a comprehensive approach: California, Connecticut, Florida, Illinois, Maryland, and New York. Fifteen states’ approaches are considered “limited”: Colorado, Delaware, Indian, Iowa, Massachusetts, Mississippi, New Hampshire, New Jersey, New Mexico, North Carolina, Pennsylvania, Rhode Island, Texas, Vermont, and West Virginia. The comprehensive approach includes some sort of provider prohibition on the practice.

California’s new law covers residents who have private health insurance plans that are regulated by the state Department of Managed Health Care (DMHC) and the state Department of Insurance, which includes about 70% of the state’s private insurance market, the California Health Care Foundation says.

However, it does not cover the roughly 5.7 million people whose employer-sponsored insurance plans are regulated by the U.S. Department of Labor.

Balance billing is a great example of what is still wrong with health care despite the repeal and replace rhetoric. It affects actual patients and families, not theoretical interests. For patients undergoing major medical procedures, such as surgery, it is often extremely difficult or impossible to gain a complete and accurate picture ahead of time as to what the cost will be to the patient. California’s new law and others like it are a move in the right direction to protect patients.

13 Ways You Might Not Realize Floods Are Like Health Care

By M2|2017-10-08T11:25:08+00:00September 13th, 2017|Insurance, Uncategorized|

13 Ways You Might Not Realize Floods Are Like Health Care

Hurricane Harvey has officially dissipated, but it has wiped out the Federal Emergency Management Agency (FEMA) disaster relief fund, and despite Congressional efforts to provide additional funds, Hurricane Irma will probably require yet another injection of relief funding before the end of September. Like most people, we at M2 are thinking about our friends and family – and all people – in the affected areas and are donating money to local organizations lending a hand.

Unlike most people, though, we at M2 are also noticing the ways these disasters and the National Flood Insurance Program mirror the issues we grapple with in health care and the ACA repeal and replace debate.

Disaster relief and health care are essentially social issues that force the government to decide who they will help and when. Which is better: paying for those affected by disaster or significant health care needs, or helping people to buy insurance against those possibilities?

If the government “helps people buy insurance,” in other words, provides subsidized insurance, how much of the premium should be subsidized? For whom should the premium be subsidized? This year the U.S. Government Accountability Office (GAO) called the National Flood Insurance Program (NFIP) high risk, in part because of a simple math problem that all insurance products must address. What happens if you can’t charge a rate high enough to cover the cost of insuring the risk?

The GAO wrote, “Since the program offers rates that do not fully reflect the risk of flooding, NFIP’s overall rate-setting structure was not designed to be actuarially sound in the aggregate, nor was it intended to generate sufficient funds to fully cover all losses.” Slightly different language, but same concept as the current fight over cost-sharing reduction (CSR) payments to health insurance companies: the government subsidizes the cost of insurance for certain people because otherwise the premiums would be too high for them to afford coverage.

Below are 13 ways you might not have realized floods are like health care (and why insurance is so important):

Personal costs are likely to far exceed a person’s ability to pay for them
When a catastrophe occurs, many people receive aid, and many who should have had insurance don’t, which may cost the government more than the insurance would have cost
Government must decide how much subsidy is enough to entice participation, but not so much as to discourage personal responsibility
States’ rights must be balanced against the federal government’s interest in sharing the expense of providing aid to people affected by catastrophic events
A small percentage of policy holders account for a large percentage of claims
Insurance is required by government, for at least some people
Insurance is subsidized by government, for at least some people
If premium rates are tied to actuarial rates, rates will skyrocket
To reduce what the government spends on subsidies without raising premiums, insurance policies with higher deductibles may be offered
Eventually Congress may establish a fee on all insurance policies sold to recover part of its costs for operating the federal program
A constant debate rages about the length of waiting periods because too short of a waiting period allows people to buy insurance coverage when they already know they will have a claim
There is some kind of national educational campaign to help people understand the importance of having insurance
Proposals are floated to ban people from receiving assistance if they have had repetitive losses

In an article called, “The US Flood Insurance Market is a Mess,” (paywall) a reporter from The Financial Times asked a reinsurer from Bermuda how to fix the U.S. flood insurance market. His response could just as easily apply to the current health care debate:

“This is a big social issue. Should mortgage companies require more people to get flood insurance? Should the government provide reinsurance, or buy more reinsurance? There is no fast and cheap fix on offer.”

N.B. Our “13 ways” list would not have been possible without the information compiled by the American Institutes for Research, The Pacific Institute for Research and Evaluation, and the Deloitte & Touche LLP October 2002 report for the Federal Emergency Management Agency (FEMA) called A Chronology of Major Events Affecting the National Flood Insurance Program.

My Experience with Obamacare

By M2|2017-10-08T11:23:43+00:00September 6th, 2017|Health Reform, Uncategorized|

My Experience with Obamacare

A few weeks ago I wrote about working with patient advocates…

While my patient advocate session was focused on Medicaid, my personal experience with Obamacare is in a different health care system, if you will, because I run a “micro-business” (fewer than 10 people) and I buy an individual policy “off-Exchange.”

My income is above 400% of the Federal Poverty Level (FPL) so I don’t receive any assistance to buy the insurance, i.e., pay the premium, nor do I receive any assistance with copays, etc. (the cutoff for cost-sharing help is 200% of FPL). Personally, I feel I make enough money to pay for insurance, and I do worry about getting into a car accident or receiving a life-changing diagnosis, so I choose to buy health insurance every year.

Even still, the patchwork system that has been built is truly not designed for someone like me. I am lucky enough to have few health problems. I fill a prescription less than once a year and when I do, it’s usually for some kind of travel-related thing, like malaria prevention. I am not writing this to brag, but simply to say, I don’t “need” health insurance other than the way I “need” homeowner’s insurance. I am insuring myself against something terrible happening. If I pay $12,000 a year in premiums, I expect I will receive no value from that expense each year except peace of mind. For some people, they do “need” health insurance because they have health care needs they could not afford to manage without that insurance.

Should the person with health care needs pay more for insurance than I pay? Well, they already do, because even if we pay the same amount in monthly premiums, they certainly pay more in deductibles, copays, and any other cost-sharing than I do because they use health care services that require those payments. The essence of insurance, whether car, home, fire, or health, is that more people pay premiums than incur claims. I am buying protection against a possible eventuality. For people with health care needs, health services aren’t an eventuality, they are a reality. That’s what insurance is for.

But the other important question is whether my purchase of insurance should be tax-advantaged in some way. I mentioned above that some people are eligible to receive tax-payer supported health insurance or health care – either because they qualify for Medicaid or because they have an income low enough to allow them to buy insurance in the Exchanges.

Should my purchase of health insurance be tax advantaged because of my job status? How about because I am an employer? That may seem an odd question, but as most of this blog’s readers know, the employer-sponsored insurance (ESI) tax exclusion is the single largest tax break in the nation. It is also worth more to people who earn more income. The Tax Policy Center estimates the “ESI exclusion costs the federal government an estimated $260 billion in income and payroll taxes in 2017.” (For comparison, the mortgage interest deduction was worth about $70 billion).

So despite my income and work status, I am eligible for tax-advantaged health insurance after all! But the patchwork nature of the U.S. health insurance system rears its ugly head again because it turns out, it’s cheaper for me to buy health insurance in the individual market (and to help my employees do the same), than it is for me to buy in the small group market. The choice is to access the tax deduction, but pay more for insurance for me and everyone in my company, or buy a plan in the individual market and pay less.

As ZaneBenefits explains, “for the majority of small groups, individual health insurance is more affordable than group health insurance because of the size of the risk pool…With a group health insurance plan if one employee has a baby, a surgery, or is diagnosed with a chronic illness, [the business is] likely to see a large premium rate increase at annual renewal time.”

Part of the debate about repealing and replacing Obamacare concerns patients with high health care needs who could lose access to care, as we have blogged about previously. However, part of the debate is also about the premium increases being seen by small businesses (and other entities as well). Members of the National Federation of Independent Business (NFIB), which represents small businesses, “have reported “The Cost of Healthcare” as the #1 problem for small businesses in Small Business Problems & Priorities since 1986.”

To be graphic, it has led to this:

The chart above from the Society for Health Resource Managers (SHRM) shows the stability of health insurance offering rates by large employers, compared to four smaller employer sizes. Notably, the smallest employer size (10 employees or fewer) represented by the black line at the bottom of the chart, has decreased by the largest percentage (36%).

My personal experience of Obamacare is a mixed bag. On the one hand, because of Obamacare it is much easier for me to buy insurance for myself as a small business owner than it was before the law passed. On the other hand, as an employer, the regulatory burden of and cost of trying to provide insurance coverage to my employees has proven to be too much for our small company to handle. Even with Obamacare, we, as a small business, are at a fundamental disadvantage when it comes to offering support for employees who want to buy health insurance.

Small businesses, defined by the Small Business Administration as those with fewer than 500 employees, comprise 99.7% of firms with paid employees, and employ 48% of private sector employees. Paying more attention to what needs to be fixed in Obamacare based on the needs of small businesses, in addition to focusing on the needs of those with serious health care needs, could lead us to more productive solutions than have been on offer recently.

There are multiple health insurance systems operating in the U.S. We either have to agree we are only going to try to tackle a couple of pieces, or we have to be more transparent about what happens if we make changes to the system that benefit someone like me (low health care needs, high premiums) or to benefit someone like the patient advocates (high health care needs, supported by tax dollars). I wouldn’t mind a little more attention being paid to small business concerns either!

Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

By M2|2017-10-08T11:26:51+00:00August 30th, 2017|Evidence-Based Medicine, Uncategorized|

Marijuana During Pregnancy: How Should Physicians Advise Pregnant Women?

As some states have legalized marijuana in recent years, for medical use and/or recreational use, the use of marijuana during pregnancy has also increased; almost 4% of pregnant women said they had used marijuana in the past month in 2014, compared with 2.4% in 2002, according to a recent study published in the Journal of the American Medical Association.

The New York Times recently highlighted the stories of several women who had written in about their experiences taking the drug while they were pregnant; of the “hundreds” of readers who wrote in, “most had smoked, while a few vaped or ate marijuana-laced edibles,” the article says. “Roughly half said they had used pot for a medical reason,” such as nausea or back pain.

“Most felt marijuana use had not affected their children, or were not sure; just a handful worried the children might have suffered cognitive deficits.”

However, the acceptance of marijuana has “outstripped scientific understanding of its effects on human health…Often pregnant women presume that cannabis has no consequences for developing infants. But preliminary research suggests otherwise.”

Indeed, “cannabinoids readily cross the placenta, entering the fetal circulation and brain, and higher fetal levels are seen with chronic use,” Jennifer Gunter, MD, an ob/gyn, points out in a June 2017 commentary.

“Another concern is that doses of THC [tetrahydrocannabinol, the main psychoactive ingredient] in marijuana have increased dramatically, from 4% in 1995 to 12% in 2014, with labs in Colorado reporting THC concentrations in some strains as high as 30%,” Gunter says. “Women choosing to use marijuana in pregnancy will be exposed to significantly higher doses compared with 20 years ago.” Also, “many strains that claim to be high in CBD [cannabidiol, the ingredient that may help nausea and pain] in fact contain little, if any.”

As for the various ways in which marijuana may be taken, “while women may think that marijuana concentrates and edibles are healthier because they do not involve smoking, they can still have significant and potentially harmful solvent residue from processing with chemicals such as butane,” she says.

“The endocannabinoid system is complex and not fully understood,” Dr. Gunter points out. “Animal studies show that prenatal exposure to THC, even at low doses, causes long-lasting neurologic changes among exposed progeny.” And in a recent meta-analysis of 24 studies of sufficient quality, women who use cannabis during pregnancy were found to have an “increased risk for anemia.” That study also found that “fetal exposure reduces birth weight and increases the need for neonatal intensive care unit admission.”

The American College of Obstetricians and Gynecologists (ACOG) recommends asking all women about marijuana use, Gunter notes. “Given the unsubstantiated reports of safety that women may find online, prenatal providers should be prepared to provide clear information about the safety concerns in a nonjudgmental way. It’s important that women get this information from their health providers so that they have accurate data to inform their medical decision-making. Prenatal providers should encourage women to report nausea and vomiting early and not downplay symptoms, as lack of help from traditional medicine may be one reason that women turn to marijuana.”

Gunter notes that ACOG “specifically recommends against advising marijuana use for nausea and vomiting in pregnancy. ACOG also recommends that providers help women who are using marijuana for medical reasons to find alternatives with pregnancy safety data.”

“Discussions about marijuana can be hard as the ‘safety’ of the drug seems entrenched,” she notes. “But I’ve found that many patients are receptive when I explain to them the extremely high concentrations of THC in modern strains, the often low levels of CBD despite advertising to the contrary, and concerns about solvents.”

This discussion highlights the fact that while some patients may assume that marijuana is safe and effective, and the main ob/gyn association recommends its members point patients toward prescription alternatives, the truth is we simply don’t know whether marijuana is safe or effective for pregnant women to treat symptoms such as nausea and pain.

This is yet another example of where data is lacking. What should physicians do in any situation in which there is insufficient data to make a recommendation? The answer as I see it: Admit researchers don’t have the answer yet. Although I realize this may be uncomfortable for many docs, it’s ok to say, “I don’t know.”

What the evidence suggests so far is the potential for cannabinoids to affect the brain and circulatory system of the baby in the womb. Thus, pointing out the potential risks of marijuana use during pregnancy, as noted by Dr. Gunter above, while acknowledging the overall lack of conclusive data, would seem the appropriate approach.

Medication Adherence: How Can We Change Patient Behavior? One Study Shows How Not To Do It

By M2|2017-10-08T11:27:38+00:00August 23rd, 2017|Uncategorized|

Medication Adherence: How Can We Change Patient Behavior? One Study Shows How Not To Do It

Adherence to medications prescribed after acute myocardial infarction (AMI) is low. Given that wireless technology and behavioral economic approaches have “shown promise” in improving health behaviors, researchers at the University of Pennsylvania recently conducted a study to find out whether a system of medication reminders that includes financial incentives and social support could delay subsequent vascular events in AMI patients.

Published in JAMA Internal Medicine, the study found no statistically significant differences between the two study arms in time-to-first-rehospitalization for a vascular event or death, medication adherence, or cost.

The use of electronic pill bottles that tracked when patients took medication, combined with monetary incentives and support from friends, family and engagement advisers, offered no significant improvement in medication adherence for patients that were recovering from a heart attack, as an article in FierceHealthcare notes.

“What we found was a little bit surprising and a little bit disappointing,” lead study author Kevin Volpp, MD, PhD, director of the Center for Health Incentives and Behavioral Economics at the University of Pennsylvania, said in an accompanying interview.

Despite the study results, the researchers still believe there is value in using technology to improve medication adherence, the article says. For example, researchers said there were indications that earlier enrollment could play a factor in the success of the interventions; because participants were identified through five different health plans, it took 40 days on average to enroll them in the program because of the delay in insurance claims, according to the article.

David Asch, MD, executive director of the University of Pennsylvania’s Center for Health Care Innovation, said one of the most important lessons of the research is the subtle distinction between various engagement strategies and how effective those are. Future research should focus on interventions that start at the time of discharge and incorporate different variations of smart pill bottles. “I think we learned enough about what went wrong in the study that may help us in designing better studies and better interventions in the future,” he said.

This study demonstrates that changing patients’ behavior is about more than just technology; a smart pill bottle is not going to suddenly convince patients to take their medicine.

One of the most significant issues to me is the 40-day average time it took to begin the program with each patient, due to delays related to insurance claims.

The best opportunity we have for changing patient behavior is at the point of care, when the patient in the hospital or the clinician’s office, and engaging with his or her health care providers. Any medication adherence program that starts 40 days after the health event in question starts out at a disadvantage; at that point, you’ve missed the window of opportunity.

State Worries Go Well Beyond Health Care Reform

By M2|2017-10-08T11:29:58+00:00August 16th, 2017|Uncategorized|

State Worries Go Well Beyond Health Care Reform

As many of you know, the M2 team focuses on state health policy. It’s a big country and we love thinking about policy in all the different ways our 50 states approach issues. In state capitals across the country, legislatures are mostly out of session, but Governors, insurance commissioners, budget officers, etc. are all busy thinking about how to best serve their constituents in the second half of 2017 and into 2018. So what are they worried about and what are they planning over the next 12 to 24 months? Here’s a quick rundown.

Revenues and Spending
Unlike the federal government, nearly every state has some kind of legal requirement to balance its operating budget annually. As such, revenues and spending dominate state policy discussions, regardless of whether the topic is health care, education, transportation or safety.

In fiscal year 2018, according to the National Association of State Budget Officers (NASBO) Fiscal Survey of States Spring 2017, governors’ budgets “display a significant degree of caution as states contend with slow revenue growth and increasing spending pressures…” More than 30 states reported tax collections below budget projections. As a result, for fiscal year 2018 executive budget proposals aim to increase state general fund spending by 1%, “the smallest spending increase recommended by governors since fiscal 2010, when state where in the depths of the Great Recession.”

The Economy and Education
Yes, states are facing slow revenue growth, and because of the need to balance their budgets, constrained spending, but governors are particularly focused on the future and various ways to grow the economy. A review of the Governors’ State of the State addresses showed a number of states focused on:

Modernizing their state’s tax structure to adapt to a 21st century economy
Reducing regulations to help businesses grow
Increasing workforce development and job training and
Increasing investments in education

Medicaid vs. Education
Increasing investments in education seems foundational for growing state economies. Notably, states spend a fair amount of money on education now, so governors are essentially saying they are spending a lot, but still need to spend more. Education and Medicaid are the two largest areas of spending in every state. According to NASBO, in fiscal year 2016, Medicaid accounted for 29% of total state spending, elementary and secondary education accounted for 19% of spending, and higher education 10% (see Total State Spending FY 2016 chart).

graph of total state spending

Looking at general fund spending instead of total state spending, Medicaid is still a major program area. In fiscal year 2016, elementary and secondary edcuation accounted for 34% of general fund spending, Medicaid accounted for 20% and higher education 10% (see General Fund Spending FY 2016 chart).

graph of general fund spending

Governors Increasingly Concerned about Drug Addiction and Mental Health
The Governors’ State of the State review noted, “several areas received more attention in this year’s State of the State addresses compared to previous years:

Toll of drug addiction, especially opioids (see map below)
The need to increase law enforcement related to drugs
The need to improve access to substance abuse treatment
Adding efforts to help drug addicts find jobs
Reforming the foster care system
New initiatives regarding mental health
Additional resources and support for veterans

State map of governors mentioning drug addiction or opioids in 2017

As the opioid epidemic continues unabated, it will force states to weigh their interest in increasing spending on education and work force training versus the need to slow and treat drug addiction. At the same time, if a state’s efforts to grow the economy include lowering taxes, revenues might be reduced at the same time spending needs are increasing. This fall, when pre-filing of bills begins, will be our first view of which states will focus on revenue, and which will focus on programs for constituents. We have our guesses, and that is what we will spend the next few months preparing for.

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