Replacing the Affordable Care Act | Health Care Reform |

Replacing the Affordable Care ActLessons From Behavioral Economics

Jonathan S. Skinner, PhD¹; Kevin G. Volpp, MD, PhD²

Sticks work better than carrots in economic terms but are politically damaging.

Republican efforts to replace the Affordable Care Act (ACA) are not over, despite the failure of the American Health Care Act (AHCA) legislation. The major challenge facing the AHCA was the loss of insurance coverage for an estimated 24 million people.¹ Any subsequent reform, especially those less costly than the ACA, will have the same challenge of keeping currently insured individuals and households from discontinuing their insurance. In this Viewpoint, we draw on behavioral economics to propose 4 general principles for health insurance reform to help ensure that the currently insured will not lose their coverage.

Incentives for Healthy Individuals

In insurance markets, healthy people subsidize people with acute and chronic disease and other health conditions. Insurance is still valuable for healthy people, because they need not be concerned about the risk of no insurance coverage in the event of unexpected injuries or acute health events. However, there is often a tendency to minimize those future risks and use the money now for more pressing concerns rather than signing up for expensive insurance. Once enough healthy people no longer elect to enroll in and purchase health insurance, a major challenge occurs, with rising premiums and the eventual collapse of insurance markets.

Incentives to encourage healthy individuals to sign up for health insurance can be described as either carrots or sticks. The ACA has both carrots (refundable tax credits) and a stick—the mandate—to ensure that healthy persons purchase insurance. Granted, the stick was not always effective; initially the amount was too small, and the penalty is too far in the future. But it was widely credited with increasing enrollment by overcoming “present bias,” the idea that potential future medical costs are discounted too much when compared with having to write a check for insurance premiums today. By contrast, current proposals rely almost entirely on carrots—tax credits for enrollees.

Behavioral Economics Principles

The first principle from behavioral economics research is that carrots do not work nearly as well as sticks; $2 in subsidies induces approximately the same behavioral response as $1 in penalties.² Furthermore, subsidies drain money from the federal treasury, whereas sticks bring in more revenue.

A second behavioral economics principle involves instant gratification; paying significant premiums means that something is received in return. Bare-bones or catastrophic plans, along with health savings accounts, do not do well from the perspective of instant gratification. Aside from the relatively few families who benefit from receiving catastrophic care, the vast majority of people do not experience any “immediate gratification” from paying those premiums, because they never reach the catastrophic cap. Even current enrollees in bronze high-deductible plans wonder why, after paying substantial premiums, they still are responsible for burdensome deductibles and co-pays.

People’s tendency to focus on immediate gratification also has important implications for the continuous coverage requirement in the AHCA. This requirement is a stick but is unlikely to work. Under this provision, if an individual who did not purchase insurance coverage now or who lets current insurance coverage lapse, would have been subject to a 30% penalty to sign up again. It is unlikely that young invincibles, young healthy people who see themselves as invulnerable who have been ignoring health insurance up until now, will suddenly become concerned about their ability to buy insurance many years down the road. Furthermore, the 30% stick would have discouraged uninsured people from buying insurance—precisely the opposite effect of the mandate.

Failure inevitably brings analysis and theory...neither of which can guarrantee success on the next go-a-round.

Replacing the Affordable Care Act | Health Care Reform | JAMA | The JAMA Network

AAMC increases projection of physician shortage up to 100K | Healthcare Dive

AAMC increases projection of physician shortage up to 100K

• The Association of American Medical Colleges' (AAMC) new estimates of the country's growing physician shortage shows it will range from 34,600 to 88,000 doctors by 2025 and from 40,800 to 104,900 by 2030.
• The AAMC's estimates in 2016 showed a projected shortage ranging between 61,700 and 94,700 by 2025.
• The number of new physicians is "not keeping pace with the healthcare demands of a growing and aging population," according to the study conducted by a division of the global information company IHS Markit. 
• The growing awareness of the physician shortage has helped many in the healthcare industry develop new strategies to better help the dwindling amount of medical professionals meet the increased demand for care services, which is partly due to a larger portion of the population having health insurance coverage. 
  These range from allowing nurse practitioners to practice independently to easing at least some of doctors' administrative burdens. The number of administrative tasks that physicians are required to do on a daily basis, including imputing health data into electronic health record systems, has been continuously cited as the main cause of burnout by physicians who have responded to surveys like the one conducted by Medscape.
  A medical student and a radiation oncology specialist wrote a shared byline published by Stat on Tuesday that argues addressing the concerns medical professionals have with debt and their financial stress will help prevent burnout and depression. They offered "six strategic solutions" to focus on, such as limiting tuition increases and increasing federal funding.
  However, the shortage is not just among physicians but also among nurses. A report released earlier this month shows nearly half of surveyed nurses (49.8%) are considering leaving the profession, which will in turn exacerbate the problem at a time when the country's aging population will continue to increase the demand for care. 
  “By 2030, the U.S. population of Americans aged 65 and older will grow by 55%, which makes the projected shortage especially troubling,” AAMC President and CEO Darrell G. Kirch said in a statement. “As patients get older, they need two to three times as many services, mostly in specialty care, which is where the shortages are particularly severe.”
  The AAMC once again recommended a multi pronged solution to the problem. This includes "expanding medical school class size, innovating in care delivery and team-based care, making better use of technology, and increasing federal support for an additional 3,000 new residency positions per year over the next five years."
• New Research Reaffirms Physician Shortage
• Physician burnout: What can be done 

AAMC increases projection of physician shortage up to 100K | Healthcare Dive

AMR teams up with Lyft for nonemergency patient rides | Healthcare Dive

AMR teams up with Lyft for nonemergency patient rides

• American Medical Response has partnered with rideshare firm Lyft to provide nonemergency transportation for patients in 42 states where the ambulance company operates.
• Hospitals and caregivers can arrange for Lyft rides via AMR’s One Call phone or online portal services.
• While millions have gained health coverage under the Affordable Care Act, many still face barriers to care because of transportation. Community hospitals average 62 no-shows a day, at an annual cost of $3 million, according to a study by BMC Health Services Research. For teaching hospitals, no-show and late arrival rates average 25% and 31%, respectively.

  Patients with multiple chronic conditions, the poor and the elderly are especially likely to need assistance with transportation. According to the Centers for Disease Control and Prevention, lack of access to transportation, along with finances and scarcity of specialists, particularly in rural areas, partially accounts for delayed care and unmet medical needs.

  The efforts by ridesharing companies are good news not only for hospitals, but for the federal government as well, which spends an estimated $2.7 billion a year on nonemergency medical transportation. That figure is expected to grow under Medicaid expansion. To boost ACA enrollment for 2017, HHS partnered with Lyft to provide discounted rides during Open Enrollment events last fall.

  Lyft also provides nonemergency rides to New York City Medicaid patients via the National Medtrans Network and through a partnership with Carelinx.
• Recent advances and integration of mobile applications such as Lyft and Uber will increase availability and accessibility for patients needing transportation.  It remains to be seen if payors and medicare will accept this mode for reimbursement without further qualifications.

Will Lyft drivers be qualified in CPR, or to assist chronically impaired riders?




AMR teams up with Lyft for nonemergency patient rides | Healthcare Dive

Future Pandemics INFOGRAPHIC

As predictions go, pandemics are one of the scariest. Inevitable and with a huge unknown quantity, pandemics are something that even the World Health Organisation are urging people not to ignore, with the frightening forecast that there will be, “sometime in the future, an event that will kill…somewhere between 80 and 90 million people.”

There are lots of hypothetical situations and theories about where a virus will come from, what it will do and the devastation it will have. In fact, there are already scientists working on vaccines that the human population may need in the event of a global outbreak. There’s actually a World Health Organisation Global Vaccine Plan!

In this infographic, we take a look at some of the possible pandemics of the future and how you can best prepare yourself against the spread of germs.

Future Pandemics

 

INFOGRAPHIC

Catholic Health Initiatives suffers $483 million in operating losses in 2016 | Healthcare Dive

• Catholic Health Initiatives is including its $483 million operating loss in its merger plans with Dignity Health. 
• CHI says the losses were due to “lower patient volumes, higher labor costs, increased pharmacy prices, and reduced reimbursement in Medicare and Medicaid,” according to a Modern Healthcare report.

An aggressive growth strategy was driving losses at CHI.  Fueled by anxiety and market share health systems merged in order to capture market and become more efficient.  The results were opposite.  

Electronic health records increase operating costs and decreased margins significantly.

Catholic Health Initiatives is not alone with the backlash on expenses, investment, and reduced in patient volume

Revenues for the nonprofit health system with 103 hospitals in 17 states increased 7.4% from $14.8 billion in 2015 to $15.9 billion in 2016. However, expenses rose 10.2% over the same time to $16.1 billion from $14.6 billion in the previous year. Losses occurred even though the struggling health system has laid off workers, sold off $600 million in real estate, and stepped back from its failed health plan.

Catholic Health Initiatives suffers $483 million in operating losses in 2016 | Healthcare Dive

Our Health California

Provider reimbursement is only a small part of what Medi-Cal pays.  It pays for indigent care, skilled nursing facilities, home health services. Providers receive only a small portion of the total budget for medi-cal patients.

The Affordable Care Act has made insurance available to many who live at or near the poverty line. However it does not assure access to providers who are the entry level into the system.

Contrary to prediction patient flows the emergency rooms have become even bigger since few providers accept medi-cal.  Medi-Cal's rates do not cover overhead for providers, and they are often seen at a loss unfortunately.

Insurance and access are two sides of the coin in regard to health care.

Click on the link to learn more about Medi-Cal and the Our Health California Community.  Join and get involved.







Our Health California

Cleveland Clinic suffers 71% operating income drop | Healthcare Dive

Cleveland Clinic suffers 71% operating income drop | Healthcare Dive

Here's the bipartisan path forward on health care: Andy Slavitt

This is the way to bringing a sensible and workable plan with bipartisan support.  No matter what the plan patients and providers need to get behind the plan . There is not perfect plan, and the perfect plan is the enemy of the good.

Trumpcare failure is an opportunity to end the divisiveness that hampered the Obamacare era.

The failure of Trumpcare last week can be seen as a rejection of policies that Americans judged would move the country backwards. But it also presents the opportunity to end the divisiveness that hampered the Obamacare era and move forward in a bipartisan direction that focuses not on destructive rhetoric, but squarely on reducing premiums and expanding access for all Americans.

The policies and the politics of Trumpcare were extreme and favored by only 17% of voters as compared with the Affordable Care Act (ACA), which enjoys support from 50%. The central plank of the bill cut care for the neediest children, elderly and disabled to pay for a large tax cut for the wealthy. The process, likewise, began with the most partisan approach possible. Republicans skirted Democratic input, avoided public hearings, and ended up rushing a bill without enough time for impartial evaluation.

The president has a chance now to turn this around. Last week, he invited Ezekiel Emanuel, a Democratic policy expert who helped craft the ACA, to the White House. Emanuel and I had dinner after his visit to the Oval Office, and he reviewed the commonsense ideas he shared with the president that were neither Democratic- nor Republican-leaning. The president had already chosen to head down a partisan path, but by inviting Emanuel, he might have signaled a potential interest in a bipartisan approach should that one fail.

Trump has an immediate opportunity to help Americans reduce their costs by choosing to enforce and properly steward what House Speaker Paul Ryan rightly called the "law of the land." The administration has the power to impact the cost of insurance by 25% to 30% with two simple decisions, according to a conversation I had with Mario Molina, CEO of Molina Health, one of the largest insurers in the exchange.

First, the administration, with support from Congress, should commit to permanently funding payments that reduce the size of deductibles for lower-income Americans (called cost-sharing reductions). Republicans need to drop a lawsuit they filed to stop these payments, or Trump needs to say they are going to continue. Second, the administration should enforce the individual insurance mandate until a different approach can be agreed upon. Those two actions will reduce costs for millions and need to be done now before insurers submit initial premiums for next year, or inaction will drive up premiums. Americans should watch this intently.

A third step would be to grant states the flexibility to increase competition and reduce costs. Non-partisan analysts such as Standard & Poor's confirm that the online exchanges that sell ACA insurance policies are stable, but in some states the cost of insurance is out of reach for those who earn too much to receive tax credits.

The administration has tools to do this, including a section of the ACA designed to allow states to pursue different approaches, including those more suited to their political philosophy, so long as they continue to meet the basic aims of covering more people with high-quality coverage. Alaska was the first to use this process last year by creating a statewide reinsurance pool. Such pools protect insurers against losses in high-cost cases, and the savings are passed along to consumers. In Alaska, the result was a dramatic reduction in premiums.

Obamacare is broken, and Republicans can fix it: Column

Medicare for All should replace Obamacare: Column

GOP should slow down and rethink health bill: Andy Slavitt

Here's the bipartisan path forward on health care: Andy Slavitt

Where are the Sexual Predators? | Kids Live Safe

A signifcant number of children are injured or are murdered by adult predators. It is a population management challenge.  Firstly to prevent these occurrences by identifying perpetrators, to identify where they live, and prevent them from contacting children.  Secondly to educate parents and children how to maximize their safety.

Attention is brought to us by large headlines, Amber alerts, missing person reports, and now on social media.  There are a wide variety of topics.  Sexual predators, Cyberbullying,Molestation, Pedophilia, Abduction, Social Media awareness, and online safety.  Kidslivesafe.com offers an online eBook which thoroughly covers all these topics.

Fortunately our system now registers all convicted sexual offenders. There is a registered database that anyone can use. For parents who want to learn where sexual predators live in their neighborhood Kidslivesafe offer a search by zip code service.












It is a public health problem, one that children are  particularly vulnerable.  Educate yourself and your children.

KIDSLIVE SAFE .  ZIP CODE SEARCH NOW

PUBMED REFERENCES



Who are Sexual Predators? | Kids Live Safe

Maine Voices: The problem isn't Obamacare; it's the insurance companies - Portland Press Herald

Only way to solve this is to fight fire.  Trumpism...negotiate from the . high point.  Write a letter to all your patients stating . you will no longer accept that company for their own good.  If 100,000 providers did that and sent a letter to the insurance company, they would back down really fast.

MILBRIDGE — With the recent news about increases in premiums for health plans sold through the Affordable Care Act marketplace, everyone wants to vilify the ACA. The ACA is but a symptom of the issue. Where are our policy dollars going?

As a primary care physician, I am on the front lines. Milbridge is remote. In good weather, we are 30 to 40 minutes from the nearest emergency room, so my office operates as an urgent care facility as well as a family medical practice.

ABOUT THE AUTHOR

Cathleen London, M.D., is a primary care physician practicing in Milbridge.

It can take 20 minutes for an ambulance to get here (as it did one time when I had a patient in ventricular tachycardia — a fatal rhythm). I have to be stocked to stabilize and treat.

We are also about two hours from specialist care. Fortunately, I am trained to handle about 90 percent of medical problems, as my patients often do not want or do not have the resources to travel. I have to be prepared for much more than I did in Boston or New York City, where I had colleagues and other materials down the hall or nearby. No longer do I have a hospital blocks away.

One evening I was almost home after a full day’s work. Around 7:30, I got a call on the emergency line regarding an 82-year-old man who had fallen and split his head open. His wife wanted to know if I could see him, even though he was not a patient of mine.

Instead of sending them to the ER, I went back to the office. I spent 90 minutes evaluating him, suturing his wound and making sure that nothing more sinister had occurred than a loss of footing by a man who has mild dementia. When I was sure that the man would be safe, I let them go.

I billed a total of $789 for the visit, repair, after-hours and emergency care costs. Stating that the after-hours and emergency services had been billed incorrectly, Martin’s Point Health Care threw out the claims and reimbursed me $105, which does not even cover the suture and other materials I used.

I called them about their decision, said that it was not right and let them know they’d lose me if they reimbursed this as a routine patient visit. They replied, “Go ahead and send your termination letter” – which I did.

That is real chutzpah !

Maine Voices: The problem isn't Obamacare; it's the insurance companies - Portland Press Herald

‘Obamacare will explode’ warns Trump after Republicans pull healthcare bill — RT America

More Hyperbole !

Despite the political backlash the GOP and Paul Ryan manned up by pulling a totally inadequate solution to replace the Affordable Care Act with the American Health Care Act.  (too many A 's in either law.

What will happen next is unpredictable.  The chances of building a coalition to approve a good (not perfect) solution is probably less than hitting a comet and landing at  less than 1 meter/second hundred's of miles away. (which we did)


Rosetta Mission's Historic Comet Landing: Full Coverage

New Format for The Health Train Express

Readers will notice our new format beginning today.  In the interest of decreasing noise and distractions we are eliminating all of the information on the side bar. Over the years it has become cluttered.  This will leave much more room for my rants.

Thank you for following Health Train during the past 11 years.  We were one of the first health blogs to appear.  Although the readership has not been huge, it has been slowly growing and noticed by health care professionals around the world.

In The Land of The Experts

Arguably, the most consequential moment of the nascent Trump administration did not place  today when Congress Votes on the first iteration of the bill known as the American Health Care Act (AHCA). If the success or failure of the bill to this point is to be judged by its reception from policy thinkers on most sides of the political spectrum, it is already an unmitigated failure.

It should be noted, and hopefully a sign of careful thinking, rather than political gain, the GOP reneged on passing a 'rush to completion" bill.

My estimation is we are only in the first trimester of the embryonic AHCA.  Delivering it now would insure a premature death.

It should be worth noting, however, that healthcare in America is a massive business accounting for 3 trillion dollars in spending with powerful stakeholders. Any real attempt at reform is bound to be opposed by those who would naturally resist attempts to dam the river of dollars that flows to them. The resistance from these parties always comes in the form of entreaties to think about patients harmed by whatever change is trying to be made.

Figuring out which stakeholder actually has the patients best interests at heart is akin to playing a shell game. All the cups look the same and its entirely possible the marble is underneath none of the cups. As a physician, I am of course, another stakeholder with inherent bias but I would submit that practicing physicians, among all the players at the table, have their interests most aligned with the patients they must directly answer to every day.

Of course the actual language of legislative bills defies understanding by mere physicians, and while my grand wish would be to leave it to the healthcare policy experts to hash out, the last eight years suggests that it is folly for the practicing physician to pay no attention to these machinations. While it may seem obvious that all parties at the table would seek to ensure the primacy of the physician-patient relationship, one can never underestimate how deep health care policy experts have their heads buried in the sand.

Who are the experts?.

Rand lists those who they think are the 'experts'.  Are they those who publish the most, who have had the most governmental positions, hold high positions in health care administration, or some other unknown selection by an algorithm ?  How many of them are physicians ?

What will be the effects of repeal, or amendment of the ACA?




Overall Rand Approach from Rand at Congressional Briefing




After reading and watching the above, hopefully we can distill who makes decisions. (If Congress really listens)







In The Land of the Experts