Tinker Ready hosts the most recent Health Wonk Review. She keeps the non-edition edition alive with a roundup of excellent but diverse submissions from the last two weeks. Read it here.
Category Archives: Health Wonk Review
Health Wonk Review: Spring Forward Edition
This has been a record-setting winter, and not in a good way (Here’s looking at you, New England). It’s also been a volatile time in the world of health policy–and the ACA in particular. We’ve had the second open enrollment period come and go, the Supreme Court has heard oral arguments around the provision of federal subsidies to health insurance exchanges not run by the states, and three Republican members of Congress have come out with a proposal to repeal and replace Obamacare. With much of the country still blanketed by snow, and the fate of the ACA up in the air until the Court’s expected ruling on King v. Burwell in June, let me assure you that there is a light at the end of the tunnel. We’ve just moved our clocks forward one hour this week, which will usher in the longer days and warmer temperatures that so many of us desperately await. As the mercury climbs higher, the snow begins to melt, and policy wonks ramp up their prognostications, I offer this Spring Forward edition of the Health Wonk Review. I hope that it will help you shake off the winter blues and be better informed about current developments in the world of health policy.
It should come as no surprise that the overwhelming majority of submissions for this edition are focused on the Supreme Court and King v. Burwell. Writing at the Healthcare Economist, blogger Jason Shafrin does a good job of presenting an overview of King v. Burwell for those who are not thoroughly familiar with the case, what’s being argued, and what’s at stake. As such, this seemed like a fitting piece to lead things off.
A close second, thanks to its comprehensive tackling of the case, is the Health Affairs Blog. While they have an entire set of posts on the topic, I’m linking solely to a post by Tim Jost, which in turn links to all the others. Tim’s post delves into the nuances of the oral arguments, looking specifically at the doctrine of constitutional avoidance raised by Justices Sotomayor and Kennedy. Lest you think that means they were suggesting that the ACA is unconstitutional, it doesn’t. Rather, it means that they were suggesting that the ACA be interpreted in such a way as to “avoid any constitutional issues.”
If that’s not enough for you, I encourage you to check out a post by Billy Wynne of the Healthcare Lighthouse. Billy’s reading the tea leaves from the oral argument and offers up his top 6 most pivotal moments during King v. Burwell. Some developments that have flown under the radar are Justice Alito’s assertion that the decision could be stayed to allow time for Congress or states to respond, if necessary, and the challengers’ concession that the context of the operative provision of the ACA is important to interpreting it. Ultimately, the post suggests that it was a better day for the Administration but warns against drawing strong conclusions from oral arguments.
After something of a hiatus, Maggie Mahar is back blogging at Health Beat. In a post asking “Will the Supreme Court Scuttle Subsidies?” she takes a clear stance. The rest of her post’s title is: No. (What Can’t Happen Won’t). Her reasoning? Legal precedent doesn’t support cherry-picking from the text of the law out of context, the Court would undermine its integrity if it sided with the plaintiffs, and the political fallout would hurt Republicans.
By contrast, John R. Graham, a senior fellow of the National Center for Policy Analysis, anticipates that the Court will find for the plaintiffs and that millions of people who are suddenly without subsidies will drop their coverage. According to Graham, however, that is not the cause for alarm that many policy wonks are suggesting. Rather, this will simply be an opportunity for Congress to work with the President to fix the various elements of the ACA that nobody seems to like. The idea is that rather than making a simple fix, Congressional Republicans can use this as an opportunity to make more significant changes to the law.
One such proposal is that put forward by Senator Burr, Senator Hatch, and Representative Upton. They proposed what they are calling the “Patient CARE Act” and I have been writing about that plan extensively of late. I encourage you to read about starting with this overview before proceeding to learn about what the GOP would like to do that will lessen consumer protections, make life more difficult for people with pre-existing conditions, reduce the amount of federal subsidies for health insurance, give more power to the states at the expense of the people, and provide more tax shelters for the wealthy under the label of consumer-directed health savings accounts.
Regardless of the outcome of the case, Wendell Potter isn’t optimistic. In a recent piece for the blog at healthinsurance.org he writes: “Regardless of how the Court eventually rules in King v. Burwell, your premiums will likely go up next year simply because the justices agreed to take the case in the first place.” He goes on to explain how the case has introduced uncertainty into the rate setting process, and how insurers tend to hedge their bets against such uncertainty by raising rates. Under that logic, you can thank those who are trying to get rid of Obamacare for raising your insurance premiums.
Fortunately, for some states that have decided to run their own exchanges, like California, King v. Burwell is irrelevant. As Anthony Wright (no known relation–although maybe he and I share consider partnering up at Wright on Health) writes at the Health Access Blog: “We have our own state exchange, and while some worry about the political fallout, I have a hard time believing the President (or for that matter, Pelosi and Reid from CA and NV) would accept a compromise that undid coverage in the states that did the right thing, like California and Nevada. With a new President, all bets are off, but that was always true.”
And, while we’re talking about the states, it’s worth noting that many states are creating special open enrollment periods for residents who are just finding out about the individual mandate (and the associated tax penalty) when they go to file their taxes this year. The issue, of course, is that open enrollment ended February 15th, while the tax deadline isn’t until April 15th. Rather than penalize people for two years, states came up with the idea to let these individuals purchase coverage if they attest that they only learned about all these requirements to have insurance or pay a tax when they went to pay their taxes. But Louise at the Colorado Health Insurance Insider tells us that this won’t be happening in Colorado. According to the state’s insurance commissioner, Marguerite Salazar: “After considering all the factors and consulting with Connect for Health Colorado, the Division determined that the negatives of starting up another enrollment period outweighed the positives.”
Of course, not all wonks lead to SCOTUS. We also have a number of wonderful submissions on a variety of topics. Among these are David Williams’ piece on emulsifiers in the Health Business Blog. He highlights an intriguing and plausible new study in the journal Nature that suggests synthetic emulsifiers that are common in processed food could be a key cause of the obesity epidemic and a trigger for ulcerative colitis and Crohn’s Disease. He says that his family is avoiding emulsifiers as much as they can, and that food companies should develop emulsifier free products now in anticipation of rising demand.
Both Joe Paduda of Managed Care Matters and Tom Lynch of Workers’ Comp Insider are focused on the topic of workers comp. Joe explains that NPR and ProPublica have published the first in what will be a series of articles on workers’ compensation. What’s striking about the reportage, he says, is how misguided, misinformed, and just plain distorted it is. Tom explains that, by law, workers’ comp is the exclusive remedy for workers who are injured on the job. He underscores that, in exchange for relinquishing the right to sue, the employee receives employer-paid medical care and temporary wage replacement, but he also asks: Is they system fair? Some new research suggests maybe not.
Over at Health System Ed, Peggy Salvatore writes about health IT, exploring the disconnect between the cutting edge technology we’re developing and our ability to implement more basic technology throughout the healthcare delivery system. The result is likely to be a lot of wasted money. As she puts it “Our society and its component businesses are financing an infrastructure that serves the needs of people who live to be 100 in a time when babies are born who will live to see 2515.”
Friend of the HWR and InsureBlog author, Hank Stern, is also exploring some of the issues with healthcare delivery systems. In particular, he’s exploring the problem of nationalized healthcare schemes and economic inelasticity. SPOILER ALERT: Every nation rations healthcare.
At Health Care Renewal, Roy Poses explores what the recent U.S. experience with Ebola–and the fiascoes at one Texas hospital in particular–can teach us about another type of disconnect: that between the preparedness of our hospitals and health systems to respond to such threats and the public relations managers that paint an undeniably rosier picture. Hospitals managers are eager to maintain their pay and privileges, he says, especially when events lead to questions about them.
And speaking of hospitals, Bradley Flansbaum of The Hospital Leader, offers some thoughtful commentary on the limitations of using mortality rates as an outcome indicator of hospital quality. It might be easy to measure, but he argues it doesn’t provide us with the whole picture.
In an interesting post on the Population Health Blog, Dr. Jaan Sidorov applies the lessons of Joel Kotkin’s book on “The New Class Conflict” to health reform. He leaves it to readers if this paranoid perspective has an element of truth or if he’s being a right wing nut job. At the very least, you’ll learn about an obscure word: “clerisy.”
Finally, it is my pleasure to welcome newcomer Al Lewis to the Health Wonk Review. Al submits two posts for your consideration. The first, co-authored by Vik Khanna, focuses on Healthcare’s Biggest and Most Expensive Urban Legend. The second, co-authored by Vik Khanna and Jon Robison, examines how Weight Loss Fines are Discriminatory and Counterproductive. I encourage you to show him some love so that he’ll continue submitting to HWR.
Well, that’s it, folks. I hope you’re now up to speed on the latest and best health policy blogging, and I trust that this edition has prepared you to go outside and enjoy the better weather. If it hasn’t reached you yet, don’t despair. It will arrive soon enough. Up next: Jennifer Salopek at Wing of Zock will host on March 26th.
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Is there an app for that?
If you ever get access to the inner sanctum of a doctor’s office, besides the dirty scrubs on the floor, the shaving kit on the windowsill, and the remains of Chinese take-out from last week perched on top of the printer, you might notice a rank of post-it’s on a wall somewhere with a bewildering array of numbers and dots. It’s always post-its or some other disposable but never-disposed-of scrap paper tacked to the walls. Those numbers are the diseases your doctors most commonly sees. In numeric form. These are called ICD-9 codes. They allow all billing, essentially. If what you have doesn’t have an ICD-9 code, you aren’t sick, you’re imagining it, go away, no one is going to get paid to see you.
Here’s something I came across while poking around at Health Wonk Review, which will be hosted, by the way, by our own Brad Wright on March 13th. Did you know that this October we’ll be getting a new ICD? No, not an implantable cardiac defibrillator, though some of us may need one of those after we see the size of the Tenth Edition of the International Classification of Diseases. Sarah Kliff, a blogger for the Washington Post, tells us that while ICD-9 had 14,000 codes, ICD-10 has 68,000. So, that’s better. It’s more, you know, numbers.
One of the reasons for the new edition, and the one proponents will tout, is actually a good one. The ICD-9 can’t expand anymore. There are no more qualifiers you can add to, say, Pneumonia NOS (not otherwise specified). The basic diseases have generally been divided by research and innovation into sub-categories based on new microscopic findings, genetic testing, etc. So it’s more specific. It’s also going to be great for moldy researchers and poverty-stricken grad students. Data-mining will be much more fun and informative. You can look up, for instance, how many doctors billed for the ICD-10 code “bitten by large turkey” presumably with a modifier if it was a wild turkey.
We doctors are understandably wary of this new edition, and not just because we’ll have to get bigger offices to accommodate all the post-its we’ll have to add to the walls. You see, it’s generally the doctor who generates the code, at least initially. So it’s more work for us. Nothing new there. Most new policies and procedures produce more work for doctors and, even more often, for nurses. But the work increase is greatest for the medical coders. The US has over 186,000 medical coders. That’s 186,000 people who work in the medical field doing absolutely nothing that has anything to do with the actual care of people. Looks like there will be more soon. Wonderful job opportunities out there college graduates!
The AMA, which is of course against implementation of ICD-10, estimates it could cost $50,000 to $8 million dollars for doctors offices to transition, and it would cost a lot of time as the billers would have to slow down until they learned the new codes. Plus there will be more coders. So, not cheap. Now, a major RAND Corporation study in 2004 estimated the potential benefits of switching to ICD-10 outweighed the costs by as much as $4.5 billion. But isn’t it the RAND corp people who said EMR was going to save the health care industry so much money?
So the new ICD codes are not money-saving. They’re not time-saving. They make zero impact on patient care, either in quality or in quantity. They do have the advantage of being more specific and generating better tracking and research data. But what is the mantra for healthcare reform? “Lower Cost, Higher Quality”?
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If You Like the Health Wonk Review You Currently Have, You Can Keep It
UPDATE: Many of the links to the great posts contained here were originally broken. I have updated them and they should now be working. This technical hiccup is simply in keeping with the theme of this edition of HWR.
For health wonks, the month of October has been the stuff of legend. Love it or hate it, the implementation of key insurance-related provisions of the Affordable Care Act has been riddled with controversy. First, the health insurance exchange website healthcare.gov encountered a glitch–much in the same way that Apollo 13 encountered a glitch on its trip to the moon. Then, news trickled out that only 6 people signed up for coverage on day one. Meanwhile, reports rolled in of people obtaining inexpensive coverage through the mostly-successful state operated exchanges. Only to be followed by the news that some 3.5 million people got notified that their current insurance policies were being cancelled and that they would be required to purchase a new policy on the exchange. Consequently, the President got called out for breaking a promise to the American people, giving this edition of the Health Wonk Review it’s theme.
Just in case you’ve somehow managed to miss the criticisms being hurled at the Obama administration during the most recent botching of ACA implementation, I offer you the words of John Goodman, who writes a post entitled “The Selling of Obamacare” on his NCPA Health Policy Blog:
“As for the president himself, he is a complete enigma to me. I’ve never felt that I understood him. He appears to have looked directly into the TV camera and said something that was blatantly untrue (in the words of Joe Scarborough) “over and over and over and over again.” You have to go all the way back to Richard Nixon to find something comparable.”
That’s one way of looking at things, but it’s certainly not the only way. Over at the Colorado Health Insurance Insider, Louise Norris counters with these words:
“Much has been said recently about how the ACA is causing a tidal wave of policy cancellations, and resulting in people losing coverage that they would prefer to keep. The frustrating part about this – as has generally been the case with every big uproar about the ACA – is that we’re not really getting a complete picture of what’s going on, and it’s hard to see the reality through all the hype and hysteria.”
Similarly, over at the Health Insurance Resource Center Blog, Maggie Mahar writes about the good news, explaining that while the media is spending lots of time focusing on Healthcare.gov‘s technical issues and warning of disaster or train wreck, they’re overlooking successes in 14 states where “the marketplaces were humming.”
Beyond the world of the exchanges, we still need to be concerned about Accountable Care Organizations (ACOs) and the Medicaid expansion–two major efforts designed to shift the system from volume to value and expand coverage, respectively. On the subject of ACOs, David Muhlestein writes a “Contributing Voices” post on the Health Affairs blog. David offers three potential reasons for the slowdown in ACO growth and concludes that the primary explanation is that there is yet no proven model to follow. He says that a crucial metric for future growth will be the renewal rate for existing ACO contracts: “If organizations are able to realize enough savings that they can remain with their ACO contract, then that is a strong indication to potential ACOs that a viable model exists that can be emulated.”
Meanwhile, Joe Paduda gives a quick update on what states are where with the decision to expand Medicaid, and predicts most will eventually expand Medicaid, because the financials are just too compelling. I tend to agree, but I think the timing of that decision will remain a political issue. As soon as the coast is clear for red states to take the money without looking like they are flip-flopping, they’ll opt-in.
And, before we shift gears, Kelley Beloff writes “You’ve Sold It, Now What Happens” over at the InsureBlog. Kelley is a Certified Medical Office Manager, and she explains the interrelationship between co-pays and EMR, and how patients can be their own best advocates.
But not everything in health policy involves health insurance. There are other issues with access to care that need to be seriously considered, and that the ACA does very little to address. At the Health Business Blog, David Williams asks whether or not veterans have timely access to mental health care. According to David, lots of veterans are not getting mental health appointments within 2 weeks according to data from the VA. No one knows how this compares to the access available to the general population, because there is no systematic tracking of appointment wait times. That’s in contrast to socialistic systems like the UK, where a great deal of data is published on wait times.
There’s also confusion in Medicare according to David Wilson of Innovative Health Media. Wilson writes about how Medicare’s Annual Wellness Visit (AWV) is confusing patients all around the country. He discusses what to expect from an AWV, and how you and your physician can use it to maximize your health.
On the supply side, Peggy Salvatore writes about the Challenges of Healthcare Training in an Uncertain World over at the Healthcare Talent Transformation blog. According to her, virtually every executive in a hospital system, a pharmaceutical, biotech or device manufacturer, or a health insurance company is trying to read the tea leaves and come up with a plan for staffing, purchasing, customer demand, vendor pricing, building and maintenance and long-term infrastructure. But all of this planning is occurring within the framework of an uncertain regulatory and reimbursement climate.
Also on the supply side, Roy Poses, who writes at Health Care Renewal, takes a look at the University of Pittsburgh Medical Center’s attempt to, in his words, “Make its employees disappear.” In his post, Roy asserts that “true health care reform would require both more leadership accountability and less power concentrated in large health care organizations.” I think he might be onto something…
Sometimes we also do things like get excited about health information technology and the potential to revolutionize the way we deliver care. In that arena, both David Harlow and Jaan Sidorov delve into health apps. Harlow writes about how mobile health apps will not realize their potential unless they can reliably engage patients. He asserts that developers should enlist patients in the effort and patients should be able to share data about their experiences as freely as they like. Sidorov reviews a recent peer-reviewed JAMA articles on health apps and goes a few steps further with some interesting insights of his own.
For the really big picture, we turn to Jason Shafrin, the Healthcare Economist, who provides a nice post on physician visits in Germany. In his post, Jason answers questions like: “How does the German government pay physicians to care for patients?” “Will a recent reform reduce access?” “And what does this tell us about the future of the Affordable Care Act in the U.S.?”
Lastly, in worker’s comp, controlling medical costs is critically important, but is a single-minded focus drowning out some of the management basics and letting employers off the hook? In Back to the Future, Tom Lynch of Workers’ Comp Insider reminds employers that they need to be in the driver’s seat to truly manage their workers comp program.
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Health Wonk Review Tackles New Questions In Health Reform
Health reform continues to be implemented, and new questions keep rising to the surface. In the latest edition of the Health Wonk Review, some of the best bloggers around take a look at these questions and provide some possible answers. Hop on over to the Colorado Health Insurance Insider and check it out!
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Maggie Mahar Hosts Wonderful Health Wonk Review
Over at healthinsurance.org, Maggie Mahar hosts the latest edition of the Health Wonk Review, with the theme “Waste, Warnings, and the Future.” She includes one of our posts on proposed Medicaid cost-sharing that falls under the “warnings” category. There’s loads of other good stuff, too. You can check it out here.
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Have Yourself a Wonky Little Christmas
Thanks to Julie Ferguson for hosting the latest edition of the Health Wonk Review on the Workers’ Comp Insider blog. If you’re wondering why Rudolph’s nose is red, why President Obama and Speaker Boehner are ignoring $200 billion in low-hanging spending cuts, or why even the most conservative Governors will eventually participate in the Medicaid expansion, then this wonk’s for you. Whether you’re sitting by the fire or just sitting in the airport, you can check it out here. And then, get ready, because I’ll be hosting the next edition in early January!
Brad Wright, PhD
Shirie Leng, MD
Nicole F. Roberts
Wright on Health 