Health Care Spending: The Flattened Curve is Reversed

Health Care Finance Administrators for the past several years have reported that health care spending had leveled off.  During the fourth quarter of last year health care spending rose 5.6% reported by the Bureau of Economic Analysis last week.

The jump triggered a sharp upward revision in the government’s estimate of consumer spending overall and accounted for nearly a  quarter of the economy’s 2.6% annualizd growth in the last three months of 2013.

Despite the number of inpatient days dipping 1% during the fourth quarter hospital revenues increased 8 billion  (more than all the previous four quarters, combined). During this last period many unemployed went without health insurance and/or limited their spending during the recession and sluggish recovery.

The 2010 Affordable Care Act incentivized hospitals to become more efficient by decreasing readmissions, and shifting costs to patients through high-deductible plans and other measures, encouraging Americans to limit visits to doctors and hospitals.

For the time being those trends may be levelling off, however there are long term upward pressures on health care costs, such as the growth of expensive high tech treatments are re-emerging.  Many uninsured Americans delayed health care treatment until the Affordable Care Act was passed.  This demographic has bottled up demand and a pool of ‘disease’ awaiting treatment that will be treated in the next several years, which will inflate health care spending. It is very likely we will see a significant increase in health care spending as the result of the ACA. Although some new organizational changes have been designed to limit increases in health spending, the proposed and hoped for results are in doubt.

Insurers now are faced with setting rates for 2015.  The time period is very short with less than 4-6 months remaining until 2015 rates are set.  Insurers (Wellpoint) predict double digit increases in rates. The rates may be different in accordance with different rates of enrollment in each state.

In the next several years the acceptance of the ACA will hinge on consumer satisfaction, and true affordability in the daily budget of family finance. The statistical outline for subsidies may be ‘fantasy”. Premium rates may change, increasing in some states and decreasing in others. If there are large increases some Americans could be once again priced out of the marketplace. Fluctuations in personal income will shift subsidy amounts, from year to year.  Some may even involuntarily be penalized if their premium policy is too much.  The new mantra may be “Do I feed my family or be penalized by the ACA”.

While somwhat unclear is an IRS statement that penalties will be taken from a tax refund, and if the taxpayer has no refund they will not pay a penalty. And according to the way the wind is blowing politically the White House may make changes accordingly.  

Although some Democrats are waxing enthusiastic about the ‘numbers’ the ultimate success of the ACA is still open to question.  Only 26% of Americans give the ACA a favorable rating.  

Obamacare When to enroll and don't panic if you have not....Next enrollment is in November 2014

Obamacare and the Affordable Care Act:   Should you enroll this year?

Probably not. HBEs will be around for a long time. There is no regulation saying there will be no further enrollment each year.  This admonition applies to providers as well as potential enrollees.

Despite pronouncements and media marketing the ACA has no track record.  It is still very early and we have seen how many enrollees have paid and have actually seen a provider.

Perhaps no more than any other misfire, the health.gov website has set back consumer and provider confidence in HIT for at least a decade.

Providers have always been skeptical regarding EHRs, and many who have already implemented systems are planning to replace them as the HHS/CMS deadlines for meaningful use approach approach. The conversion from ICD-9 to ICD-10.                                                                        is also on the horizon.

The requirements for more complexity follow rapidly one upon the other. Mingling with these changes is the affordable care act, which will cause fallout and expected increases in insurance premiums, copays and deductibles.  The expected fall out will take several years to become apparent.

The ‘algos’ will devise statistical anaysis to show how much healthcare spending has been reduced by the affordable care act.

California has been spotlighted by the relatively high numbers of enrollees as compared to most states.  California is one of the states that agreed to expand Medicaid using temporary federal subsidies.  Governor Jerry Brown saw this as an opportunity to grab federal funding for an insolvent state. These federal subsidies will end in 2016, with a complicated analysis of how much of the federal largesse has been spent so that states can repay and excess spending in excess of the federal allotments.

Californians seem to leap before they leap..It is similar to building a ‘bullet” train in the central valley, where the population density is low, for the sake of ‘easy’.  In a state that is insolvent it makes little sense to ‘borrow money’ to expand medi-caid.  Neither has anyone elaborated on what that means?  If eligible for medi-aid do applicants go through an additonal eligibility process at their county public social services agency? Is there a share of cost for those who make more than $ 900.00/month?  Details have not been forthcoming?  Medi-caid operates on a monthly financial status which results in an almost impossible method of accesssing health care. In addition Medi-caid has far fewer eligible providers and reimbursement rates are far lower than the lowest subsidized insurance plans. Coverage is far from uniform between medicaid and subsidized policies.  The devil is in the details.

If your income is in the Medi-caid eligibilty bracket determine what your share of cost will be each month. Usually maintenance allowance is about $900.00 for the first person and increases about $ 400.00 for each eligible beneficiary    This is good catastrophic coverage but if your income is above the poverty threshold expect to pay for your own medications, and doctor visits.  Remember this share of cost is a monthly amount, it is not a truly annual  deductible.    Medi-caid also has a limit on assets for eligibilty.

California, Texas and Florida rank the highest in uninsured. Texas however has refused to expand it’s medicaid program or accept federal subsidies to do so. These are border states, although Florida is not, but has a large immigrant population from Cuba and Central America.   

The American Association of Physicians and Surgeons (AAPS) has listed ten reasons to not enroll in ObamaCare.

Here are their top ten reasons for not enrolling and what you might do instead. Weigh the pros and cons, then decide the cost-benefit balance best for you for you

1. Obamacare Health Insurance cost signifianlhy more-likely more than the penalty (tax) in the first several years.  Most people can expect their monthly premiums to double. This may vary from state to state.

2. Obamacare health insurance policies limit your choice of doctors.

3. Obamacare health insurance policies limit  your choice of hospitals.  Some centers for excellence and national cancer centers are included.

4. Out of pocket costs will skyrocket, Obamacare Health Insurance Policies have double and triple the deductibles, and higher copays you must pay before coverage kicks in.

5. Much of your medical privacy is lost, despite HIPPA, and control of your information is in government hands. (IRS administration of premiums and tax penalties)

6. The

Federal Health Benefit Exchange website is an unfinished tool with no linkage to insurers, and has not yet been demonstrated to be secure.

7. If you use an ‘Obamacare Navigator” their credentials are far less than an insurance broker who is certified, and expercienced in explaining insurance to consumers.

8. Open to question are the protection of Second Amendment rights as medical databases expand and collect information on such things as sexual preferences, and gun ownership

9. Obamacare enrollees are finding it very difficult to cancel or change their plan once enrolled if they find a better plan.

10. Obamacare policies are basically ‘managed care, with limitations on your options and reward incentives for providers to restrict care.

Continued

Portions of this article are from an online blog “Health Train Express”  (Gary M Levin MD)

The author has been on the faculty of Loma Linda Universitiy School of Medicine, USC-Doheny, and the new UC Riverside School of Medicine. He owned his own medical corporation, and also has practiced in the U.S. Navy, and the Veteran’s Administration.  His medical experience transsitioned from conventional fee for service, health maintenance organizations, IPAs, and prepaid contract medicine.

                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                                          

Obamacare (Affordable Care Act) What now ?

Affordable Care Act. Who to believe ?

Democrats are enthused about the increasing numbers of enrollees in the ACA (Obamacare), and see it as the arbiter of the ultimate ‘success’ of the law.  Republicans are not impressed with the number of enrollees.

Democrats  (President Obama) have reacted to public pressures by delalying mandates, extending enrollment periods and have accomodated insurers and providers in some specific ‘hot button’ issues.  It seems congress only responds to a critical issue when public pressure mounts, as indicated by a public poll.  The numbers vary greatly from week to week, depending on the hot topic and it’s resolution.

What is a health issue has become a political football. Health does not belong in this arena at all. It began with Medicare when congress passed the law establishing Medicare along with other Title IX benefits.  Unfortunately it was passed, and then it was not administered nor modified until a number of crises developed.  Passing a law and then ignoring the challenges it created is typical of our system of governing.

The Affordable Care Act begins and follows the same process. Nancy Pelosi ® a highly visible supporter for the ACA proclaimed “We  won’t know what  is in it, until it is passed.

It is common knowledge now that most legislators did not or could not read through the entire law which is about 1200 pages.  This was followed by  a second but later law (less known) which further elaborated on the ACA.

Republicans want the law amended in major ways or outright repealed.  Most Democrats still support the law, and some are no longer satisfied now that the law has gone into effect.

It remains to be seen if Republicans and Democrats can still open a dialogue as to what changes are necessary, even before Congress makes any further decisions. All of this would have been avoided if each party had accomodated the different opinions.

Congress made decisions based upon recommendations from many authoritative private and public organization who advise CMS and HHS.  These organizations make recommendations to Congress in formation of health law.  Congress then evaluates recommendation and passes law which may not be a true consensus of opinion.  Specific law often is modified by financial considerations.  

Other considerations are how Congress governs health care issues in the midst of other decisions for Defense, Foreign Relations, Science, Education and other departments. At the end of the day when budgetary issues set a limit on  expenditures a decision may be made which eliminates a vital portion of the law that effectively creates a major problem in the implementation of the law.

The next 24 months will expose operational issues, and whether the calculations for risk pools are accurate. This still depends upon how many enrollees actually pay for policies and continue to make premium payments.  Operational issues also include to providers, hospitals, and limited or non-existent access to provider networks..In many areas centers for excellence for cancer, heart disease.

Enrollees will find provider participation differs for Covered California and/or Health.gov for private insurance is not the same for subsidized policies vs private insurance.

The two most features for Obamacare are the elimination of pre-existing conditions as a reason for denial, an unlimited life-time benefits Enrollees must also be aware that some treatments or diagnostic procedures will require review and authorization prior to services.

What is totally neglected in the media and the propaganda from HHS and Health Benefit Exchanges is the fact that"

THE NEXT ENROLLMENT PERIOD BEGINS ON NOVEMBER 1, 2014....ONLY SEVEN (7) months away.

Unless you are a medicaid recipient or have an urgent need, we recommend waiting until November 2014.  By that time some of the operational issues should be more apparent, such as provider networks, copays and deductibles

SAYING GOODBYE.....TO YOUR EHR

What remains the same in HIT since 2004 is a farily uniform opinion on the usability of EHR in daily clinical practice. (Doubt)

What  MD has not already spoken about the unusability factor buried deep in your key board and/or mouse. The requirements for HIPAA security, Meaningful use attestations, and interoperability are key requirements for MU.

30% of   EHR  users are dissatisfied with their current EHR and plan to replace them. (KLAS)   If your practice is one of them and you are faced with a large expense to upgrade your HIT system you will want to find a new EHR that meets all MU requirememts.

Vendors have received considerable feedback (criticism) about their present system’s inadequate framework for clinical patient flow and have time to redesign their software.

Prior to the finality of MU3 now may be the time for a new EHR.

The confluence of the Affordable Care Act, proposed Accountable Care Organizations, Increasing meaningul use mandates, improved Cloud services, vendor experience leading to some improvement in user friendliness, and user experiences and demand provide a fertile environment for change.

Calculating ROI with the old system vs a new one has to do with flow, efficiency, and the cost of replacement. If your EHR runs in the cloud the decision is simple...the changes are done at the host site. All software changes are performed off site in the vendor’s facility. eliminating any work disruption at the clinic.  Your original vendor contract should have had stipulations for the added expense of upgrading to meet eventualities of MU or other requirements. Since there is much competition among vendors, a competitive advantage may be the offering of enhanced maintenance and software upgrades.

If you are ‘retiring” your present system due to regulatory changes, consult with your accountant and legal counsel whether you can accelerate the depreciation and write off a portion of the expected life of your old system.  If possible this may ease some of the pain of a poor investment.

Most EHRs were built upon  features present in a practice management system, designed to maximize reimbursement, and maximize charge for each encounter. The new paradigm will be based not upon volume but upon improved outcomes, and decreased cost, for at least some of the encounters.

The field of ACO is new,  everyone knows what an ACO is supposed to do, but it is hard to find one. Several ACOs now are operating and some early statistics show savings and reduction in costs.

Interoperability is a requirment of MU1 and the ONC encouraged this with a framework for disparage EHRs to communicate with each other. Regional Health Information Exchanges experienced a challenge in developing sustainable business plans not dependent upon long term government grants, although the HITECH Act provided start up capital.  A new niche industry developed for HIE infrastructure.  

Some hospitals and providers have committed to these HIEs, but there is a significant difference between potential users and those in the HIE.  Many providers have interoperable systems, and have attested to it’s use. However many do not use the feature either because pre-existing methods are in use or there are no other providers to communicate.

An analysis of our regional health information exchange IHIE.org reveals this fact. The analysis is from the largest HIX in Southern California, and may differ significantly from other organizations.

Accountable Care Organizations will require data and the HIX may provide that avenue to collect and display operational numbers for the ACO.  HIX may become more affordable with expanding functionality to include ACOs requirments without building an entire new infrastructure.

HHS AND WAR ROOMS

CMS opened three “War Rooms” during the start of the Health.gov website. It was a high priority for the White House Chief of Staff, Denis McDonough who commuted almost daily between CMS headquarters in Bethesda, MD  (home of CMS) and  1600 Pennsylvania Avenue. It was so disorganized that 3 war rooms were needed either by design or by default.

The ‘Joint Chiefs’ of Health.gov included CMS head Marilyn Tavenner, Jeanne Lambrew, and HHS head Kathleen Sebelius.  The group failed to find ‘actionable intel’ about how and why the website was failing for all to see  They resorted to opening their laptops at the White House and tried to log on to health.gov .

The initial findings were the website was not able to process the number of simultaneous users. Five days after it’s opening Todd Park, the U.S. Chief Technology officer told USA Today health.gov was designed for 50,000 simultaneous users, and 250,000 attempted to use it at the same time.  The real amazing fact was that  Todd Park was never involved in the design of the system. Park is a highly successful health-care tech entrepeneur.  During the redesign it was found the site was designed to only handle a few thousand users.

Chief of Staff Denis McDonough’s assignment was to determine if it (Obamacare)_should be abandoned entirely.  Yes, on October 17 the President was ready to scrap the whole thing.

The HHS War Rooms

CMS opened three “War Rooms” during the start of the Health.gov website. It was a high priority for the White House Chief of Staff, Denis McDonough who commuted almost daily between CMS headquarters in Bethesda, MD  (home of CMS) and  1600 Pennsylvania Avenue. It was so disorganized that 3 war rooms were needed either by design or by default.

The ‘Joint Chiefs’ of Health.gov included CMS head Marilyn Tavenner, Jeanne Lambrew, and HHS head Kathleen Sebelius.  The group failed to find ‘actionable intel’ about how and why the website was failing for all to see  They resorted to opening their laptops at the White House and tried to log on to health.gov .

The initial findings were the website was not able to process the number of simultaneous users. Five days after it’s opening Todd Park, the U.S. Chief Technology officer told USA Today health.gov was designed for 50,000 simultaneous users, and 250,000 attempted to use it at the same time.  The real amazing fact was that  Todd Park was never involved in the design of the system. Park is a highly successful health-care tech entrepeneur.  During the redesign it was found the site was designed to only handle a few thousand users.

Chief of Staff Denis McDonough’s assignment was to determine if it (Obamacare)_should be abandoned entirely.  Yes, on October 17 the President was ready to scrap the whole thing.

DISAPPOINTING TO SAY THE LEAST

In the beginning there were over 40 million uninsured in the United States. President Obama said, “This is not good “ and commanded “Let there be light” and behold it was so (or was it?)

The latest figures for the uninsured who have enrolled in  the Affordable Care Act is around 4.6-5.0 million.  The original number targetted by health.gov was 5.0 million new enrollees.   Their goal was very conservative since the original number for the uninsured was over 40 million.

Either way the reality is that the number of uninsured has only diminished to 45 million. Perhaps HHS and CMS were prescient in setting such a low goal to not disappoint, or make themselves feel successful.

The 5.0 million enrollees was the threshold for the new algorithms to guarrantee solvency for the new risk pools, and that may be why that goal was named.

Unfortunately the enrollment period ends on March 31st.  This date is not an arbitrary date mandated by HHS, and is the insurance industry standard for enrollments.

There is nothing preventing the date from being extended.

The options would be to:

1. Halt enrollment and  have enrollees insured this year.

2. Continue enrollment throughout 2014

3. Consider halting further enrollment until another plan is designed.

Many uninsured evaluated the offers and decided to wait and see. Many factors were in play, including provider directory errors, web site difficulties, subsidized rates were confusing as generated by the benefit exchanges. There was a lack of clarity how Medicaid would be expanded and no details in regard to financial requirements, assets, family size, etc.  For those familiar with Medi-caid there are asset restrictions to remain eligible for Medicaid.    There was no mentioin of how  ACA Medicaid is different from ordinary Medicaid.

Those who have already enrolled should not be disadvantaged by a newer version of the ACA and can be maintained until the new program is operatiional.

Government, insurance companies and other regulators have piled more bureaucracy with each new idea on how to save money.  Each change decreases reimbursement and increases overhead for providers and hospitals. Despite this never-ending demand, providers and hospitals have outsmarted all these efforts as a meaure for survival.

The initial result is not only disappointing and reveals the inadequacy of the planners and the impossibility to predict demographics of enrollees.

The only thing which will guarrantee solvency will be federal guarrantees. This may be the first phase of a health industry bailout .  The Federal Reserve needs to warm up the printing press.

AFFORDABLE CARE ACT AND RISK ANALYSIS, OR WHAT WILL MY PREMIUM BE IN 2015?

ACA and Risk Analysis

Health Insurance companies may be at great risk participating in ObamaCare. Some large insurers have taken a ‘wait and see” attitude.

Setting insurance policy premiums can be challenging.Obamacare has already set a limit on administrative expenses and the amount that must be spent on patient care by insurers.

ESTIMATING RISK FACTORS:

Obamacare and Health benefit exchanges add another set of unknowns. The ACA stipulates that pre-existing illness cannot be a reason for denial of insurance. This eliminates any means of estimating risks in the newly insured. Statistically speaking young persons spend less on healthcare, which is why health benefit exchanges must sign up many young people who do not consume healthcare vs. older patients who consume much more.  

There is no real experience on risk pools in the ACA.  Perhaps there may be some estimation by looking at previous risk pool analysis in each demographic.  However the availability of insurance to previously uninsured could produce an entire new set of figures.  So, despite not being able to use pre-existing conditions as a parameter for insurance, insurers such as Blue Cross and Blue Shield of North Carolina is asking enrollees to fill out health risk assesments by offering free gift cards to those who fill out the survey.  In addition they are encouraging screening tests, and initial primary care visits for evaluation. It is hoped this will accelerate the rate setting process.

Insurers are not confident in forecasting premium rates for 2015. Even if statistics from January 1, 2014 until mid 2014 are utilized it is still a very short time period for newly insured to obtain health care.  Many uninsured can be expected to seek out health care for neglected and longstanding chronic conditions.  Utilization figures could be biased by this initial demand for health services.

Most statisticians would most likely prefer a 24-36 month period to determine risks.