DOCTOR PUNDIT » Healthcare Delivery

Insurers Balk at Childrens Coverage under Reform; HHS Clarifies Administration Policies

Michael Douglas, MD, MBA — Thu, 29 Jul 2010 14:21:25 +0000

The theory of the moral hazard hypothesis goes something like this: moral hazard occurs when a party isolated (set-off) from risk may react differently than it would if it were fully exposed to the risk. In the case of risk aversion, insurers are stepping up concerns that families will seek coverage under new reform laws only after their children fall ill. They contend that the ability to keep this from happening will contain costs and premium increases.

The White House seemed to be waiting for the line to be drawn in the sand before responding to this potential reform-killing measure — that is, until Insurance essentially threatened ending children-only plans under reform altogether in some states.

Some state insurance commissioners expressed concern that, without an open enrollment period that was widely communicated, people might wait until their children got sick to enroll them in coverage, causing plans’ costs to increase. And we were concerned when last week, some indicated that insurance companies would choose to stop offering policies for children rather than cover kids with pre-existing conditions.

HHS has since clarified the administration’s position on this matter issuing an advisory stating the formation of open enrollment periods, outside of which coverage will not be provided. Now, the distinction between children with congenital and pre-existing conditions and those with acquired, high-cost diagnoses is more clearly defined — for the purposes of the insurance companies, that is. | LINK

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A Patient Concern of a Different Sort

Michael Douglas, MD, MBA — Wed, 28 Jul 2010 15:21:09 +0000

No matter the moniker (beneficiary, patients-as-consumers, healthcare consumers, policyholders), the economics-speak of healthcare reform places the person at the very center of it — the patient — left to assess two very basic questions with each care encounter: (1) Did I get my reason for access to a mode of care addressed? and (2) [How much] will I have to pay for it? Seems as though this poor soul is not too happy about having to acknowledge this bit of healthcare cognitive dissonance.

“Why am I being billed for services I never wanted to get?? Because health care providers think they can simply do what they want and people will have to pay for it, or their insurance company will. That is wrong.”

Sometimes the meaning of life is easier to come up with. | LINK

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Maryland Program Aims to Establish Healthcare Exchange Standard under Reform

Michael Douglas, MD, MBA — Fri, 23 Jul 2010 13:24:48 +0000

What do you get when old-fashioned community activism meets 21st century social media tech? Perhaps the best politics-is-local example of reforming healthcare access so far after its passage on a national scale. Howard County, Md. – approx pop. 250 000 — is partnering with a tech firm with one simple goal in mind: to guarantee access to healthcare for its uninsured.

Its mechanism looks to be a harbinger for reform-based enterprises such as local healthcare exchanges/cooperatives (whether subsidized or not) within which members pay a monthly fee for basic services. These services may run the gamut of primary care — as acute hospitalizations, preventive medical treatments and screenings, and emergency medical access would be covered.

Perhaps even more important, the utilization of concierge providers as healthcare “coaches” as both an empowerment mechanism and compliance tool, ensures continued healthcare access, sound preventive care, and decreased future healthcare costs. Will it serve as a model for state-based healthcare exchanges under reform? Looks like it’s on its way. | LINK

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AMA Cries Foul over Insurers’ Utilization of Quality Parameters to Maximize Efficiency

Michael Douglas, MD, MBA — Tue, 20 Jul 2010 05:14:20 +0000

In a reform environment in which appearances are everything, providers could be looking to the AMA for some help. Some physician groups/health systems, the AMA says, could be unfairly targeted by insurers’ quality ratings to steer patients toward systems they deem more “efficient”, creating a somewhat dubious practice reputation for those health systems cited as “inefficient”. Insurance companies counter that, in this age of reform, the delivery and coverage marketplace will have to adapt to measures, they say, are being mandated by the Obama administration as necessary mechanisms of reform and quality.

The AMA is particularly worried about individual physicians being rated by insurers. The doctors’ group says physicians who are deemed expensive may be looking after sicker patients, or the claims data may simply be inaccurate.

A very simplistic view by the AMA, as the 21st century patient and healthcare consumer is able to make informed decisions on provider networks based upon resources unavailable to them just a few years ago. Patient advocacy groups, disease advocacy organizations, support groups, and … even insurance companies themselves are sources of care informatics designed to “steer” patients to where they should be seeking care based upon the best available data matching their unique chronic care needs. Healthcare quality doesn’t just appear out of nowhere; it must be earned. Patients cannot benefit from it without physicians who are capable of providing it.| LINK

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Health Reform Implementation Requires Greater Efficiency in Chronic Disease Management

Michael Douglas, MD, MBA — Mon, 19 Jul 2010 13:11:06 +0000

As President Obama’s vision of healthcare reform begins to gel in the minds of physicians, health systems, insurers, and policymakers alike; the phased rollout of coverage mechanisms by Big Insurance will provide a timeline of sorts into the character of reform from a third-party perspective.

Via mandates, deadlines, and tax breaks; insurance coverage will be moving forward in the first half of the 2010s at a deliberate and measured pace — eventually covering some 30 M Americans without coverage and adequate access, as promised by Obama. One of the care delivery mechanisms is in the coordination of care of those with chronic diseases (such as diabetes, obstructive lung disease, and asthma) and the incentivization of primary care providers in those systems who choose to embrace such a plan.

Coordination of care reduces the fragmentation of delivery to those with chronic illness. Improving referral systems, rewarding primary care providers’ participation in innovative models such as the medical home, and emphasizing the importance of preventive care services in reimbursement schemes are important first steps to increasing access, decreasing acute care costs, and increasing quality in healthcare delivery. | LINK

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Under Reform, Insurers Will Cover Certain Preventive Medical Costs

Michael Douglas, MD, MBA — Fri, 16 Jul 2010 13:26:49 +0000

The U.S. Preventive Services Task Force, an independent, non-partisan body made up of primary care physicians involved in developing preventive medical guidelines based upon evidence-based medicine, has always reveled in its staunch self-governance. That could change ever so slightly in the new age of health reform.

The academic research-oriented group will continue to make recommendations on best-preventive practices and supply ratings (“A”, “B”, etc.); but this time, under reform, insurers will be required to cover services that receive such a rating. The Obama administration hopes that this increase in access (which will require a small premium increase by insurers in the near term) will reap savings in the future — as costs for preventive testing, screening for certain chronic diseases, vaccinations, and well-child visits would be covered (without health plan co-pays and deductibles) if so rated by the USPSTF.

Besides having to consider methodology involved in formulating its ultimate recommendations, the group will also have to contend with the specter of political agenda setting if lobbying groups and disease advocacy organizations have their way under this bit of legislation — scheduled to go into effect in September. | LINK

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Research Trends Positively Influence Approach to Alzheimer Dementia

Michael Douglas, MD, MBA — Thu, 15 Jul 2010 19:59:16 +0000

Research into better treatments and possible cures of Alzheimer dementia is one of the bright spots in the potential for better healthcare delivery in the decade of the 2010s. There are many signs that bode well for the approach to this disorder at the dawn of the second decade of the 21st century.

New research into alternate pathways of disease development is starting to generate excitement among primary care physicians and geriatricians (such as myself) as potential arenas for new classes of drugs to combat Alzheimer’s. Better care delivery models in long term care of the elderly as part of new initiatives in the Affordable Care Act are already starting to impact chronic disease care management strategies.

Perhaps most important, there is new evidence to suggest that earlier detection of this cognitive disorder can enhance those developments, and more. At an annual meeting of top dementia researchers, guidelines were proposed to expand on the research from the ’00s to diagnose the disorder earlier — a strategy that benefits more than just those potentially afflicted with Alzheimer’s.

If the guidelines are adopted in the fall, as expected, some experts predict a two- to threefold increase in the number of people with Alzheimer’s disease. Many more people would be told they probably are on their way to getting it. The Alzheimer’s Association says 5.3 million Americans now have the disease.

Heavier use of newly discovered biomarkers for earlier detection of the pathology behind Alzheimer dementia will be a closely watched process by both physicians and health policy analysts alike. | LINK

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Obama Announces First National HIV Policy Strategy

Michael Douglas, MD, MBA — Mon, 12 Jul 2010 14:17:10 +0000

HIV is once again in the news lately — first with news of a new strategy to combat the infection with enhanced vaccination research, the commitment of HHS in reallocating funds for HIV research on a global scale, and now the creation of the first “national HIV strategy” by a sitting president.

In the report, the administration calls for steps to reduce the annual number of new H.I.V. infections by 25 percent within five years. [..] [T]he administration will redirect money to areas with the greatest need and population groups at greatest risk, including gay and bisexual men and African-Americans.

Obviously, simple “redirection” of federal funds for medications and treatments of HIV/AIDS is not the final mechanism of care access for the millions of patients afflicted with this chronic disease; it is unclear where these funds will provide an absolute siphon for spending. Kudos to the administration in its efforts to reacquaint an entirely new generation of Americans on the urgency of this disease, but it’s got a long way to go to reduce sharply its transmission rates and healthcare policy atrophy in this area. | LINK

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Obama Appoints New CMS Head

Michael Douglas, MD, MBA — Thu, 08 Jul 2010 14:46:23 +0000

The fact that President Obama is naming Don Berwick, MD, CMS head via recess appointment shows his commitment to quality in healthcare delivery. It’s welcome news given that his drive for cost and access were the other cornerstones of recently passed reform legislation. Via the WH blog:

There’s no question that Don Berwick is the right choice to be our next CMS administrator: he’s the founder of the Institute for Healthcare Improvement and has spent decades as a practicing physician and a Harvard professor. He’s dedicated his career to finding ways to make our health care system work better for patients and cost less for taxpayers.

The choice of Berwick to fill this post is the perfect fit for an administration in search of the holy grail in healthcare delivery: quality. | LINK

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Massachusetts Faces Uphill Battle with Legislative Efforts to Control Healthcare Spending

Michael Douglas, MD, MBA — Tue, 06 Jul 2010 11:35:14 +0000

Those who expected the state with the first-in-the-nation initiative to cover the health care of all of its citizenry will have to hold their collective breaths a little longer. The plans for an overhaul on how physicians and hospitals are paid for quality delivery are on hold as major parties cannot come to an agreement on how this metric should be implemented. Perhaps the thought of examining Massachusetts’ negotiated payment system as a relatively straightforward exercise in healthcare economics was a bit shortsighted.

Combine the complexities of fee-for-service government reimbursements with the intricacies of funding for coordinated care systems; the possibilities of funding an accountable care commission of sorts as a payment governing body; and the simple inertia that current levels of healthcare spending have created in a wasteful state system — and you’ve got a recipe for an overwhelming stalemate. There is a glimmer of hope that one faction’s action will get the legislative ball rolling on this issue: some hospital systems in the state plan to release details on the creation of governance to oversee spending in their ranks. | LINK

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