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.

Options for Obamacare Health Insurance Policies.

Options for Obamacare Health Insurance Policies.

Depending on  your level of income there are several options.

1. Purchase a very high deductible catastrophic medical insurance policy

2. Use your monthly saving to put money into your self-funded medical savings accout you control.

3.Consider joining a religious group cost-sharing program such as Liberty Healthshare,Christian care, Medishare and Samaritan Ministries.

4. Seek out direct pay practices imaging centers and hospitals that offer discounts for cash-pay for only the services you choose.  These practices and hospitals save significant overhead by not billing insurance companies to only be denied.

5. Consider medical tourism and purcase a ig-deductible international health insruance policy for much lower premiums that offer medical services in lower cost countries such as Chile, Costa Rica, Panama, Mexico, Singapore, Tailand,  India and others. There are professional agencies that provide these services.  Many foreign medical providers are educated in the United  States and the United Kingdom.

Our overall advice is to take control of your medical care in your own hands in partnership with physicians of your choice

At it’s core, Obamacare is about controlling YOU, and limiting your choices for medical care and how you spend your money. Obamacare is not about “affordable care” or “patient protection”

Fourth Down and Ten to Go

Your health is a political football.

There are some Democrats that are disenchanted with the Affordable Care Act, however the majority still seem intent upon disregarding the early warning signs of catastrophe.

Public opinion:  According to a CNN poll  39% of Americans say they support the heal th care law, up from 35% in December, which was it’s record low. The four percentage point increase is within the survey’s sampling error. Fifty-seven percent questioined say they oppose the measure, down five points from December.”

This is the good news ?

The White House says that 4.2 million people have signed up for coverage on the exchanges but have refused to report how many have actually paid, and are therefore enrolled.  It is estimated that only 1 million of those who  “signed up”  were previously uninsured. These numbers fail to make a serious dent in the nearly 50 million people promised help by Obamacare.

from the National Review Online: The Corner March 17, 2014

IS THE AFFORDABLE CARE ACT SUCCESSFUL ?

The number of enrollees in the Affordable Care Act probably bears little upon whether it will be a success.  Proponents admittedly are disappointed with the lack-luster enthusiasm for the Affordable Care Act.

The most influential aspect of the Act is to guarrantee eligibility for those previously uninsured, or who have pre-existing medical conditions often used as a reason for denial of coverage.

It is not affordable, universal, socialized medicine, nor a health plan. The ACA is also not uniform and differs from state to state. The decision of a state to not expand medi-cal for uninsured made it unavailable for some.

Congress failed to develop a competent bill and passed a bad bill largely because of the ‘hubris’ of leaders of congress and President Obama developing a health law with little if any input that was listened to from authorities, and/or persons who work in the health care sector.

Obamacare needs to be repealed, one way or another. World affairs are now diverting media and congressional attention from health to serious world affairs.

Health IT internships ONC HIMSS & ACO

“Health IT internships may be another means of meeting demands for HIT personnel in the health workforce”, according to Healthcare IT NewsDay.

HIMSS 2014

Although the REC programs have trained students in basic heallth information technology, hospitals and others report they have little practical experience, and are seeing an influx of students entering these programs who do not have clinical or information technology backgrounds.

Meaningful Use, Stage III and ICD 10 conversion are two two features scheduled for implementation later this year. Providers have indicated the challenge of performing this change simultaneously before the deadline.  HHS has indicated it will delay the ICD 10 conversion, and still insists on Meaningful Use.

“The Unvarnished Truth” is what CEO Mark T. Bertolini believes is what people want to hear during tough times.  Much of the controversy and tension between providers and government relates more to the timing of transformation rather than it’s content or goals.

There is very little meaningul communication or response to provider comments unless the conversation becomes very loud.

ONC (The Office of the National Coordinator), Four national coordinators discussed their years driving the health care information adoption over the past ten years.

Startups have created competition for funding and much interest by venture capitalists in health related strategies for improving healthcare with technology.

2014 promises to be a transformative year for HIT was a discussion at a CMS Townhall meeting.

Despite the challenges the United States is Set to Be the World’s Largest EMR Marketplace. Meaningful use did one thing right, filling hospitals and doctor’s offices with EMRs, despite controversy.

EMR is over ten years old and is no longer in it’s infancy, and is now an adolescent. Significant growth and early maturation now have positioned the EHR to become transformed just as adolescence transforms pubsence into adulhood.

Accountable Care is driving disparate hospitals to merge, be bought or buy neighboring systems. Individual organizations may very well use different EMRs.  Health information exchanges, either intra or extra hospital become a vital business and clinical information structure.

During and after the Affordable Care Act the HIT system must be flexible, and designed to be totally interoperable to serve health providers.

The End is in sight (Open Enrollment..that is

In several weeks (March 31 2014) the  open enrollment for  Obamacare will end for year 2014.   Many will pontificate on how successful or the opposite the affordable care act will be based on the initial numbers of who has enrolled.

Many in health care already know that IT never solves a problem by itself. IT is there to assist or enhance operational efficiency. HBE was only necessary because HHS, CMS and Obama wanted a rush job to fuel the startup of the affordable care act.   By itself the health.gov website, and coveredca.com did little to create an affordable care system. The ACA still has critical and possibly fatal flaws waiting to happen in the next several years.

Despite serious and growing concern about the present state of the ACA all segments of the industry have already planned to transitiion to a new system. Although the Republicans have offered alternatives to the fractious components of the ACA any legal  changes will not come until the mid-term elections, and even then it will require moral and political will to make a substantial change.

President Obama has already made many changes in regard to mandates, and waivers using executive privilege.  After the next Presidential election if the congress and/or presidency changes hands, the new President may use the same mechanism to amend, rather than  repeal Obamacare.

To be certain the current resident of the White House will use executive privilege and other administrative methods to modify ‘blocks’ to implementing the  Affordable Care Act using waivers, exemptions, delaying implementation dates, and whatever means are necessary to eliminate opposition to Obamacare.

PPACA and Outpatient Procedures

HealthCare LeadersMedia reports the Affordable Care Act will cause the number of outpatient proceures to increase for those opted-in for Medicaid expansion in the PPACA. And according to figures there is a spread seen as examined by state.   By 2015 California stands to perform 46 million outpatient procedures, while a state such as Texas (opted-out for Medicaid expansion) will decrease by 53 million cases.  (reported by Truven Health Analytics)   

These figures are further broken down by specialty. Two specialties which create a significant number of ambulatory surgeries, and among the top tier of expense are cardiology and orthopedics.  Medicaid opt-in vs opt-out produces some signifcant differences in reimbursement that outweigh numbers of cases.  The split per  specialty mirrors that of the total number gained or lost in 2016.  

Mental health services (Psychiatry) are already in short supply and  have previously been throttled by the lack of reimbursement by insurers.  PPACA has mandated an increase in these services as a covered benefit. For those states who are opted out the medicaid eligible population will suffer relative to states opted-in. Those who live in states opted-out of Medicaid expansion will not have access to insured  care for outpatient psychiatry services.

As expected the variance is greatest for California and Texas which are outliers in the data. In 2016 the volume of Cardiology cases in Califonia will increase by 672,000, while Texas will forgo 840,000 cases.  These figures also reflect population differences and the number of medicaid eligible patients in each state.

For orthopedic surgery California (opted-in) will benefit from over 299,000 outpaitent orthopedic cases, while states such as Florida and Texas (opted-out) stand to lose near 300,000 orthopedic cases.

The choice to opt-in vs opting out not only effects who will receive benefits in the eligible  population but will have significant effects on the hospital industry.  The number of outpatient surgeries outweighs the number of inpatient surgeries.  Using the present fee for service reimbursement rates under FFS hospitals have been advantaged by higher reimbursement reflected by higher cost.  The loss of coverage for medicaid eligible patients not only places them in jeopardy, it also creates significant differences in the infrastructure necessary to deliver these services.

Outpatient services in states who have opted-in will need a business plan to expand capacity which includes not only physical plant, but skilled workers, such as surgical techs, surgeons, expendables as well as revising operating schedules, reducing turn-a-round times and the like.

DME suppliers will reap these benefits in opt-in states.

The figures represent the number of cases gained vs the loss of gain by opting out. The opt-out numbers are a speculation, and do not represent an actual decrease in cases.  The number of procedure in any case will not decrease in states that have opted-out.

Increased demand for services always encourages efficiency and technical breakthroughs, to decrease loses and encourage profitability, much as occured with small incison cataract surgery and the development of small incision surgery in cardiology,general surgery and orthopedic surgery.

While ‘futurists’ attempt to predict the effects of the new law, serendipity and the butterfly effect can be expected  to yield surprising changes as well.

This article also appears in Health Train Express, February 22, 2014. http://healthtrain.blogpot.com

The author also publishes at Digital Health Space http://digitalhealthspace.blogspot.com

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