Unbiased Analysis of Today's Healthcare Issues

Friday Links

Written By: Jason Shafrin - Feb• 20•15

Coordinating Federal Efforts for Patients with Serious Mental Illness

Written By: Jason Shafrin - Feb• 18•15

Following up a December 2014 Government Accountability Office (GAO) report, testimony last week Linda T. Kohn, Director of Health Care at the GAO describes how fragmented the federal government provides very fragmented support services care for individuals with serious mental illness.  Coordinate across agencies is lacking and few agencies have conducted evaluations of their programs.

Agencies identified 112 federal programs that generally supported individuals with serious mental illness in fiscal year 2013. The majority of these programs addressed broad issues, such as individuals suffering from homelessness, which can include individuals with serious mental illness. The programs were spread across eight federal agencies: DOD, DOJ, DOL, Education, HHS, HUD, SSA, and VA….
Interagency coordination for programs supporting individuals with serious mental illness is lacking. HHS [the Department of Health and Human Services] is charged with leading the federal government’s public health efforts related to mental health, and SAMHSA [Substance Abuse and Mental Health Services Administration]  is required to promote coordination of programs relating to mental illness throughout the federal government…
Agencies completed few evaluations of the programs specifically targeting individuals with serious mental illness. As of September 2014, of the 30 programs specifically targeting individuals with serious mental illness, 9 programs had a completed program evaluation—7 by SAMHSA and 2 by DOD.

Ms. Kohn concludes with the following.

In conclusion, individuals with serious mental illness can face significant challenges getting the services they need. The public health, social, and economic impact of serious mental illness, coupled with the constrained fiscal environment of recent years, highlights the need to ensure that federal programs efficiently and effectively use their resources to support
the complex needs of individuals with serious mental illness

Below you can see a the types of SMI programs by agency.

Regional Growth in Medicare Spending, 1992–2010

Written By: Jason Shafrin - Feb• 17•15

Below is an abstract from a paper I co-wrote with Camille Chicklis, Thomas MaCurdy, Jay Bhattacharya, and Dan Rodgers.  The title of the paper is Regional Growth in Medicare Spending, 1992–2010.
Objective: To determine if regions with high Medicare expenditures in a given setting remain high cost over time.

Data Sources/Study Setting: One hundred percent of national Medicare Parts A and B fee-for-service beneficiary claims data and enrollment for 1992–2010.

Study Design: Patients are classified into regions. Claims are price-standardized. Risk adjustment is performed at the beneficiary level using the CMS Hierarchical Condition Categories model. Correlation analyses are conducted.

Data Collection/Extraction Methods: The data were obtained through a contract with CMS for a study performed for the Institute of Medicine.

Principal Findings: High-cost regions in 1992 are likely to remain high cost in 2010. Stability in regional spending is highest in the home health, inpatient hospital, and outpatient hospital settings over this time period. Despite the persistence of a region’s relative spending over time, a region’s spending levels in all settings except home health tend to regress toward the mean.

ConclusionsRelatively high-cost regions tend to remain so over long periods of time, even after controlling for patient health status and geographic price variation, suggesting that the observed effect reflects real differences in practice patterns.


The Republican Response to Obamacare

Written By: Jason Shafrin - Feb• 17•15

For years, Republicans have campaigned to repeal Obamacare. The biggest question in their campaign is what to replace it with. One year ago, Republicans unveiled the Patient Choice, Affordability, Responsibility, and Empowerment Act (Patient CARE).  Now, the Republicans have a new plan.   What’s in the new plan?  The Healthcare Economist reviews the highlights.

  • No lifetime limits. “…insurance companies would be prohibited from imposing lifetime limits on a consumer”
  • Less restrictive community rating. “Under Obamacare, insurance companies are banned from charging older Americans more than three times what they charge younger individuals…Our proposal would repeal this costly mandate and…adopt an age rating ratio that limits the amount an older individual will pay to no more than five times what a younger individual pays in premium dollars (5 to 1) as a federal baseline…after the adoption of our proposal, any state could adopt age and family rating rules that are more or less restrictive than the federal standard.”
  • Dependent coverage to 26.  Like Obamacare, the Republican plan would allow adult dependents to stay on their parents insurance until age 26, but it would also allow states to opt out of this provisions if they should so choose.
  • Guaranteed renewability.  Insurance companies will not be allowed to cancel insurance coverage except in the case of fraud.
  • End of the individual mandate.  The individual mandate would be repealed, but…
  • “Continuous Coverage” protections. “Under this new protection, individuals moving from one health plan to another—regardless of whether it was in the individual, small group, or large employer markets—could not be medically unwritten and denied a plan based on a preexisting condition if they were continuously enrolled in a health plan.”  Although the individual mandate would be repealed, individuals would have an incentive to retain coverage because only by being continuously enrolled in health insurance could a person ensure they are not disqualified from the continuous coverage provision. “Insurers would be required to offer coverage at standard rates based on age and residence to individuals who have stayed continuously insured with at least catastrophic coverage for a period of at least 18 months, without a significant break in coverage, similar to the HIPAA protections that exist under some circumstances today. So long as an individual, or family in the case of a family policy, has stayed continuously covered, they could not be forced to pay a higher premium solely because of a costly health condition when switching plans.”
  • Subsidies based on age and income.  Individuals would receive a subsidy to purchase health insurance.  This subsidy would depend on the individual’s age, household composition (e.g., single vs. family) and income.
  • High-risk pools.  The goal would be to use some federal funding to help states cover the highest risk patients.  This will drive down premiums for the general consumer, but states’ budgets will certainly take a hit unless federal funding is generous.
  • Medicaid reform.  Obamacare expanded access to Medicaid; this plan aims to reduce the number of Medicaid beneficiaries.  The proposal states that “individuals eligible for Medicaid would also be eligible for and have the choice to use the health tax credit to help purchase health coverage.For example, if a state chose to auto-enroll an eligible individual into Medicaid, that individual could retain the right to opt-out of Medicaid and use the health tax credit to purchase health coverage.”  The federal funding for this program would grow at inflation + 1%.  The proposal would also allow states to experiment with health opportunity accounts (HOA) that Medicaid beneficiaries could use to fund health care expenditures out of pocket.
  • Malpractice caps. The Republican proposal would place caps on non-economic damages and limitations on attorney’s fees.
  • Tax deductability of health insurance.  The Republican proposal “…caps the tax exclusion for employee’s health coverage at $12,000 for an individual and $30,000 for a family.”  This is similar to Obamacare’s “Cadillac tax”, except the thresholds are even higher.

Government IT

Written By: Jason Shafrin - Feb• 16•15

Information technology without a doubt is helping to restructure the very fabric of society, business and government.  However, these changes do not come without challenges.  For instance electronic health records (EHR) may harm the patient-physician interaction and are susceptible to hacker attacks.

A recent Fiscal Times article demonstrates how government programs often do not invest in IT infrastructure efficiently.

Meanwhile, the government has seriously struggled with its IT projects—most notably the launch of HealthCare.gov, the federal portal built to facilitate the sale of health insurance set up under Obamacare. The website, was so plagued with tech problems at the start of its rollout that only six people were able to sign up on the first day.

Eventually, HealthCare.gov received a massive revamp and repair effort that ballooned the project’s price tag to more than $2.1 billion, Bloomberg reported. Watchdogs still worry that it could be vulnerable to hackers.

Though HealthCare.gov is the most publicized federal tech flop, there are plenty of other examples where the government bungled an IT project. The Pentagon and the Veterans Affairs Department, for instance, abandoned a $1.1 billion program to build an integrated electronic health record system after failing to get the systems to communicate. In fact, almost none of the systems built are compatible agency to agency.

Why are government IT projects so expensive? There is no one answer, but for Healthcare.gov, the answer is partly due to poor organization. Bloomberg reports:

The construction of healthcare.gov involved 60 companies, supervised by employees of the Centers for Medicare and Medicaid Services instead of a lead contractor, according to the inspector general at the Health and Human Services Department. The project was marked by infighting among the contractors, CMS officials and top officials at HHS, the Cabinet-level department that oversees CMS, according to e-mails released Sept. 17 by the House Oversight and Government Reform Committee.

The GAOs 2015 High Risk List now includes “Improving the Management of IT Acquisitions and Operations” as one of its top risk to the federal budget.

Friday Links

Written By: Jason Shafrin - Feb• 13•15

Valentine’s Day HWR

Written By: Jason Shafrin - Feb• 12•15

Then Valentine’s Edition of Health Wonk Review: For Health Policy Lovers Everywhere has been posted by Peggy Salvatore at Health System Ed.

Why isn’t there more mental health drug innovation?

Written By: Jason Shafrin - Feb• 11•15

There have been a number of efforts emphasize the importance of mental health and put mental health treatments at the same level of respect as physical health.  For instance, there was the Mental Health Parity Act of 1996 and also The Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA) , which:

…requires group health plans and health insurance issuers to ensure that financial requirements (such as co-pays, deductibles) and treatment limitations (such as visit limits) applicable to mental health or substance use disorder (MH/SUD) benefits are no more restrictive than the predominant requirements or limitations applied to substantially all medical/surgical benefits.

Despite, these efforts, drug development for serious mental illness has lagged behind physical health treatment developments. One reason is restrictive reimbursement policies. For instance, the head of R&D&D at mental health drug specialist Lundbeck stated that government pricing restrictions made the development of drugs to treat mental illness less enticing for Pharma.

“Over the past five or six years, many of the major companies have actually pulled deliberately out of the area because they foresaw the systems that governments have to curtail their costs,” he pointed out to us. “They basically apply metrics that are not appropriate for mental health treatment.

“There has been no willingness to pay for the medication when it comes out. And if that’s the case then companies would obviously much rather research and invest in other therapeutic areas where there is an apparently higher appreciation of what we bring. That’s how simple it is.”

Although there is much rhetoric about the importance of treating mental health, society’s priorities will only change when key stakeholders put their money where there mouth is.

Autism vs. Measles

Written By: Jason Shafrin - Feb• 10•15

A powerful article from Medium about an autistic person’s view of the measles debate:

No matter what other lofty ideas of toxins and vaccine-related injury anti-vaxxers try to float around in their defense, that’s really what all of this is about: we’re facing a massive public health crisis because a disturbing number of people believe that autism is worse than illness or death. My neurology is the boogeyman behind a completely preventable plague in the making.

The title of the article is: “I’m Autistic, And Believe Me, It’s A Lot Better Than Measles”


Written By: Jason Shafrin - Feb• 09•15