- Winners and losers.
- Is the U.S. really an HCE outlier?
- No IO in UK?
- Basic income’s version of the RAND HIE.
- What is CAR-T?
Peggy Salvatore has posted the “May You Live in Interesting Times” Edition of Health Wonk Review at Health Systems Ed Blog, and as you might expect in a week that saw the release of the Republican’s proposed Obamacare replacement plan, it’s a solid, jam-packed edition.
There has been a lot of criticism of the Republican’s “repeal and replace” bill known as the American Health Care Act. The critiques are coming from both the left and the right. Let’s look at just one provision–the premium age bands–to better understand why both people on the left and right do not like the American Health Care Act for very different reasons.
Consider the provision that insurers can set the price of health insurance for older Americans at up to five times the premiums of younger Americans. This provision will result in higher premiums for older individuals. The AARP writes:
“Before people even reach retirement age, big insurance companies would be allowed to charge them an age tax that adds up to thousands of dollars more per year. Older Americans need affordable health care services and prescriptions.
While it is true that older Americans will receive larger tax credits through AHCA, these credits likely will not offset the additional cost. Thus, AARP is concerted about whether near elderly individuals will be able to afford health insurance on the private market.
Michael Cannon is from the Cato Institute and also does not like the premium age band provision either. However, he believes that community rating is the problem and that that the 5 to 1 premium ratio is too narrow rather than to wide. He writes:
ObamaCare’s community-rating price controls literally penalize insurers who offer quality coverage to patients with expensive conditions, creating a race to the bottom in insurance quality…The leadership bill would modify ObamaCare’s community-rating price controls by expanding the age-rating bands (from 3:1 to 5:1) and allowing insurers to charge enrollees who wait until they are sick to purchase coverage an extra 30 percent (but only for one year). Even with these changes, however, premiums would remain high, ObamaCare would continue to make it easier for people to wait until they are sick to purchase coverage, and the law would continue to penalize high-quality coverage for the sick. In fact, the House leadership’s decision to leave ObamaCare’s community-rating price controls in place while relaxing its “essential health benefits” requirements would cause coverage for sick to deteriorate even faster than ObamaCare does.
So the AARP wants health insurance to be affordable for consumers on the demand side. The AHCA may not make enough progress on this front for many constituencies. At the same time, Cato wants to make sure suppliers (i.e., insurers) are able to set actuarially fair premiums rather than have a narrow premium bands under community rating. By keeping the community rating provisions of Obamacare–even with some age-related premium variance and some penalties–not only is the risk of an adverse event death spiral high, but insurers have an incentive to provide poor quality service to high-cost individuals (e.g., those with cancer) because they are money losers.
A more reasonable solution would be the “Best of Both Worlds” proposal from the American Enterprise Institute. The two primary provisions of this proposal include:
This plan works because it is both market-based and equitable. Allowing insurers to set their own prices addresses the Cato Institute’s concerns as it means that markets will function and we will not see mass exits of payers for certain markets. Government premium support subsidies addresses the AARP’s concern that health insurance is not affordable. The AHCA’s simple 5:1 premium bands by age are crude and do a poor job of aligning subsidies with likely premium costs. By better tying government subsidies to expected market premiums, health care would remain affordable for all.
Before we get into the details of how the American Health Care Act bill will proposed to change the current system, let’s first talk about what is not changing. In fact, while “repeal and replace” has a catchy ring to it, there is a lot that is staying the same. As Ezra Klein of Vox notes, Obamacare provisions that remain include:
So what did change?
Tomorrow, I will weigh in with my comments on the bill.
Interesting facts from Alex Tabarrok of Marginal Revolution:
One percent of all the physicians in the United States come from the six countries targeted in Donald Trump’s new Executive Order. I found that a surprisingly high number. According to the Immigrant Doctors Project, those 7000 physicians provide 14 million doctors’ appointments each year and many of them are located in the poorer, whiter, and rural parts of the country.
I don’t see this as a knockdown argument against the policy but it does illustrate a surprising cost and also how much the United States benefits from the immigration of the highly-skilled and educated.
How do you measure the quality of care patients with cancer receive? How long they live? Avoiding side effects? Patient satisfaction? Process measures?
Further, there are multiple types of cancer and different cancer have different recommended treatments and methods of providing care. To further complicate the issue, new cancer treatments are being introduced in rapid succession; what qualifies as high quality cancer treatment today may be out of date months or even weeks later.
So what are the options? Provide uber-detailed qualty metrics for each individual tumor type (or even within tumor type)? Measure quality of care broadly? Or give up on the whole top-down quality measurement endeavor.
A recent paper by Valuck et al. (2017) examined current quality measures and practice guidelines for 10 tumor types:breast, chronic myelogenous leukemia (CML), colon, kidney, melanoma, non-Hodgkin’s lymphoma (NHL), non-small cell lung (NSCLC), ovarian, pancreatic, and prostate. Then, they asked a panel of experts how these quality measures should best implemented in practice.
The group determined that overreliance on condition-specific process measures is problematic because of rapidly changing evidence and increasing personalization of cancer care. The group’s primary recommendation for enhancing measure sets was to prioritize and develop effective cross-cutting measures that assess clinical and patient-reported outcomes, including shared decision making, care planning, and symptom control. The group also prioritized certain safety and structural measures to complement condition-specific process measures.
They also come to some sensible recommendations:
VBP models should leverage the best available measures, beginning with those identified by the CQMC, as well as monitor adherence to pathways and incentivize PRO data reporting.
Payers and providers should use a layered measurement approach for performance improvement, monitoring, and accountability measures, aligned across the physician, system, and external accountability levels.
Measure developers (e.g., ASCO, ASTRO, and NCQA); program implementers (e.g., CMS, state Medicaid agencies, Medicaid managed care organizations, and commercial health plans); and industry should continue to support, fund, and develop cross-cutting measures, including clinical outcomes and PRO-PMs, leveraging collaborative processes such as the NQF Incubator.
Public- and private-sector payers, measure developers, and industry should incorporate best practices to improve measure specifications, evaluate the impact of measures used in accountable care programs, and address measurement methodological issues in model design and measurement (e.g., risk adjustment and stratification and provider attribution), as identified by groups such as HCP LAN and NQF.
Research organizations, such as the Agency for Healthcare Research and Quality and Patient-Centered Outcomes Research Institute, and industry should fund measurement science, including PRO-PM design and implementation.
Overall, an interesting perspective on measuring and paying for quality.
Cost effectiveness research aims to determine if the benefits of a treatment outweigh the cost. But which benefits should be included? How should we weight improvements in different outcomes? What data and methods need to be used to measure benefits and costs?
These are questions that academics typically think of as within the domain of research experts. However, there is another group of experts that is often ignored: patients.
A 2012 JAMA commentary from Mullins, Abdulhalim, and Lavallee (2012) discuss specific points to involve patients in the process. In particular, they advocate for continuous cost effectiveness research. This process would incorporate patient feedback on direction through the entire research process. The 20 steps they outline are detailed below.
Mullins and co-authors lay out a convincing case. Although patients have hetergeneous clinical backgrounds, treatment preferences and technical sophistication, if cost effectiveness reserach aims to ultimately to improve the value of care patients receive, it would be a disservice not to include patients themselves explicitly in the research process.
Tonight, President Donald Trump delivered his first address to a joint session of Congress. Although the speech touched on a number of topics, I give my line-by-line commentary on the portions of the speech related to health care.
“Tonight, I am also calling on this Congress to repeal and replace Obamacare with reforms that expand choice, increase access, lower costs and at the same time provide better health care.“
“Mandating every American to buy government-approved health insurance was never the right solution for our country. The way to make health insurance available to everyone is to lower the cost of health insurance, and that is what we are going to do.“
Obamacare premiums nationwide have increased by double and triple digits. As an example, Arizona went up 116 percent last year alone. Gov. Matt Bevin of Kentucky just said Obamacare is failing in his state, the state of Kentucky, and it’s unsustainable and collapsing.
One third of the counties have only one insurer, and they’re losing them fast, they are losing them so fast. They’re leaving. And many Americans have no choice at all. There’s no choice left.
Remember when you were told that you could keep your doctor and keep your plan? We now know that all of those promises have been totally broken. Obamacare is collapsing and we must act decisively to protect all Americans.
“Action is not a choice; it is a necessity. So I am calling on all Democrats and Republicans in Congress to work with us to save Americans from this imploding Obamacare disaster.”
“Here are the principles that should guide Congress as we move to create a better health care system for all Americans.
First, we should ensure that Americans with pre-existing conditions have access to coverage and that we have a stable transition for Americans currently enrolled in the health care exchanges.“
“Secondly, we should help Americans purchase their own coverage, through the use of tax credits and expanded health savings accounts, but it must be the plan they want, not the plan forced on them by our government.”
“Thirdly, we should give our state governors the resources and flexibility they need with Medicaid to make sure no one is left out.”
“Fourth, we should implement legal reforms that protect patients and doctors from unnecessary costs that drive up the price of insurance and work to bring down the artificially high price of drugs and bring them down immediately.”
“And finally, the time has come to give Americans the freedom to purchase health insurance across state lines which will create a truly competitive national marketplace that will bring costs way down and provide far better care. So important.“
“Everything that is broken in our country can be fixed. Every problem can be solved.”
Consumer Reports‘ “Choosing Wisely” initiative aims to identify high-cost, low-value treatments that can often be avoided. One question remains is why do providers still offer these services? Do payer coverage policies or reimbursement rules affect these choices?
A paper by Colla et al. (2017) attempts to answer that question. The authors used commercial payer claims data from the Health Care Cost Institute (HCCI) and Medicare administrative data to examine whether the use of low-value care is similar between Medicare and commercially insured populations within a hospital-referral region (HRR). Both data sets covered the period 2009 to 2011. The low-value measures of interest included: “imaging for back pain, vitamin D screening for low-risk patients, cervical cancer screening for patients over age 65, prescription opioid use for migraines, cardiac testing in asymptomatic patients, short-interval dual-energy X-ray absorptiometry (bone density) testing, preoperative cardiac testing in low-risk patients preceding low-risk (noncardiac) surgery, and a composite of these.”
The authors found that these low value services were provided fairly frequently. About one in ten women over age 65 received a cervical cancer screening, but preoperative cardiac testing before low-risk noncardiac surgery occurred in 1 in 4 eligible commercially-insured patients patients and almost 1 in 2 insured patients that had surgery. This reflects either that physicians are providing too much low-value care, or that Choosing Wisely’s conception of what low-value care is does not meet the definition of patients, physicians and/or payers.
Regarding the geographic variation in use of low-value services, the authors find the following:
We find a high correlation between overuse in the Medicare and commercially insured populations across HRRs (ranging from 0.54 to 0.90). The tendency to deliver or avoid low-value care appears largely independent of payer type (Medicare or commercial) and patient population attributes.
In short, it is likely that provider treatment practices rather than differences in payer policies drive use of these “low value” services. Because many commercial plans follow Medicare policy and physicians likely treat most insured patients similarly regardless of the type of insurance, this finding should not be entirely surprising.