The Independent Payment Advisory Board and Medicare Spending: New Research Suggests a Change in Our Medical Culture

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Launch of the ACA’s controversial Independent Advisory Board– a  panel charged with  recommending ways to curb Medicare inflation — has been delayed until 2016. Does this means that the IPAB’s critics have won?

No. IPAB was, from the beginning, only meant to serve as a backstop. The law says that the board will be asked to recommend places where we could pare Medicare spending if—and only if—Medicare inflation begins to outstrip inflation in the rest of the consumer economy.

But over the past three years Medicare spending has decelerated; it is no longer growing faster than the economy as a whole. This is why Medicare’s chief actuary has decided to put IPAB on hold.

Some observers argue that as the economy recovers from the Great Recession, the nation’s health care bill is bound to climb. I disagree. Particularly in the case of Medicare, I don’t think that the economic downturn explains most of the slowdown. 

 I believe that reform is already having  an effect on health care inflation:  Four years of debate over the Affordable Care Act has made us more aware of the waste in our health care system. Patients are asking more questions, and providers know that they are going to be held accountable for that waste.

                                 We Still Need IPAB as a Backstop

That said, in the future, spending could pick up–and we may need IPAB. This is why President Obama has made it clear that he will veto any attempt to eliminate the Board.

It is important to know that IPAB exists, as a reminder to drug companies, device makers, nursing homes and others that, one way or another, we can no longer afford a system that is wasting $1 out of $3 of our health care dollars on over-priced, unnecessary tests and treatments that, too often, put patients at risk without benefits.

If, and when, IPAB is asked to recommend cuts it will use medical evidence to decide where to trim. IPAB is likely to recommend lower payments for certain services and products that medical research tells us are now “overvalued”–based, not on cost-benefit analysis, but on patient outcomes. If patients who fit a particular medical profile are not helped, Medicare should not cover the treatment for those patients.

As I have explained in the past, IPAB is not the panel of bean counting bureaucrats that Obamacare’s opponents suggest.  IPAB will not “ration” care; it is charged with making care more rational by letting Science–rather than lobbyists– decide what Medicare should cover.  Moreover, Congress can veto IPAB’s recommendations, if legislators can agree on  ways to achieve equal savings– without rationing care, or shifting costs to seniors.

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PSA Testing: An About-Face

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If you thought U.S. doctors would never accept evidence-based medicine, consider this: Just last week, in a stunning about-face, the American Urological Association(AUA) announced that it no longer recommends routine annual PSA testing for men under 55.   

The organization added that “men ages 55 to 69 who are considering the PSA test” for prostate cancer “should consult their doctors about the test’s benefits and risks.”

The potential “benefit of preventing prostate cancer mortality in 1 man for every 1,000 men screened over a decade” should be weighed  “against the known potential harms associated with screening and treatment [which include side effects such as incontinence and impotence }  For this reason, ” shared decision-making is recommended for men age 55 to 69 years that are considering PSA screening,”  The AUA stressed that “ patients’ values and preferences” should direct a final decision.

.In addition,  the AUA announced that “to reduce the harms of screening, a routine screening interval of two years or more may be preferred over annual screening in those men who have participated in shared decision-making and decided on screening.

I wrote about “shared decison-making” and how it could help patients considering a PSA test make an informed choice  here on HealthBeat back in 2007.(Readers interested in why this protocol is so important to patient-centered medicine may be interested in this story that I wrote for Dartmouth Medicine: “Making Choice An Option.” )  Congratuations to the AUA for having the courage to take this giant step forward into the future of medicine.

“The new guideline is significantly different than previous guidance,” the organization acknowledged, noting that it “was developed using evidence from a systematic literature review rather than consensus opinion.” In other words, urologists didn’t take a vote; they looked at the Science.

Authors of the new guidelines have “learned very quickly that there really was no high-level evidence supporting the use of screening with PSA,” said urologist H. Ballentine Carter, who chaired the panel that wrote the new guidelines.”                         

When I last wrote about PSA testing, in July of 2012, such a radical shift in the AUAs positions would have been unthinkable.  At the time, the U.S. Preventive Services Task Force (USPSTF) had given PSA testing a grade of “D”—suggesting that benefits did not outweigh risks. 

 In response, urologists joined forces with Republicans to threaten the autonomy of the USPSTF by supporting  a House bill (H.R. 5998)  that proposed to mandate “greater role for specialists and advocacy groups” in developing guidelines”  while ”eliminating the Department of Health and Human Services’ secretarial discretion to withhold Medicare funding for interventions that lack convincing evidence for benefit.”      

What a difference a year makes.

The Affordable Care Act and the Smokers’ Penalty

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Under the ACA smokers  buying insurance in the Exchanges will have to pay a 50% “Premium Surcharge.” For a 55-year-old smoker, the penalty could reach nearly $4,250 a year. http://news.yahoo.com/penalty-could-keep-smokers-health-overhaul-205840155.html Does this mean that Americans who smoke won’t be able to afford coverage?

No. In the end, most smokers should be able to get health insurance without paying a stiff penalty.

For one, it’s up to individual states as to whether they want to let insurers charge smokers more. By early April of 2013, Rhode Island, Vermont, Massachusetts and D.C. had voted to eliminate smoking premiums in their health care exchanges:  The American Cancer Society, which is opposed to the surcharge, is working to persuade other states to ban it. (The ACS explains: “We’re anti-smoking, not anti-smoker.”)

I agree with the ACS that the penalty is counter-productive.  If it makes insurance unaffordable for some smokers, this means that they won’t have access to smoking cessation programs, nicotine patches and other drugs that could help them quit.  Keep in mind that most smokers want to quit, and these programs have proved extremely successful.

The good news is that many Americans who are addicted to nicotine will be eligible for Medicaid. In the U.S. 39 percent of adult smokers live below the poverty level. . Many more live below 133 percent of the poverty level. As states expand Medicaid, they, too, will become eligible for the program. Since Medicaid charges no premiums, they will not pay a premium surcharge.

Meanwhile, new research by the George Washington University School of Public Health and Health Services indicates that including comprehensive tobacco cessation benefits in Medicaid insurance coverage can result in substantial savings for Medicaid. The study found that every dollar spent on tobacco cessation program costs resulted in an average program savings of $3.12, which represents a $2.12 return on investment. 

Under the Affordable Care Act all state Medicaid programs are required to cover tobacco cessation medications, beginning in 2014.

Finally smokers who receive health benefits from their employer are likely to find that they don’t have to pay the premium if they join a smoking cessation program.

Breast Cancer “Awareness”: Marketing Fear — Part 1

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 Peggy Orenstein is a brave woman. A breast cancer survivor, she has faced up to the fact that perhaps, if she hadn’t had a mammogram that revealed a tiny tumor when she was 35, it might have vanished on its own. She would not have known that it existed—and would not have undergone a lumpectomy plus six weeks of radiation.  Nor would she have suffered the emotional consequences of being told, at age 35, that she had breast cancer.

At that age few of us are ready to come face-to-face with our own mortality.  In last Sunday’s New York Times Magazine, she writes: “Recalling the fear, confusion anger and grief of that time is still painful.”

But sixteen years after her diagnosis we have learned more about breast cancer, and Orenstein is willing to look the truth in the eye:  “As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later?”

Regret is a tough one. After making a major decision that has life-changing consequences, few of us want to consider that we might have made the wrong call.  Instead, most women in Orenstein’s position say: “I’m so glad I had that mammogram. It saved my life!”

 Orenstein herself confesses, “that is what I used to say. I even wrote that in the pages of this magazine.

But if she hadn’t had the mammogram, and the cancer wasn’t discovered until she felt a lump, wouldn’t it have spread? Wouldn’t she be dead?

No. As Orenstein point out, “Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones.  Early detection is based on the theory, dating back to the late 19th century that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap.”

But science has advanced since the late 19th century, and we now know that just isn’t true. Sometimes breast cancer invades other parts of the body. Sometimes it doesn’t. The problem is that mammograms can’t tell us which cancers will spread.

                                  The Likelihood Of Over-Treatment               

What many women don’t realize is how commonplace the harmless cancers are. When someone is told she has breast cancer, she is likely to imagine a large, ugly lump, buried somewhere in her breast. Yet as Dr. David H. Gorski,  a surgical oncologist at the Barbara Ann Karmanos Cancer Institute who specializes in breast cancer explains: today approximately 30% to 40% of breast cancer diagnosis”  are examples of “ductal carcinoma in situ (DCI)”—cancers that begin in the milk ducts and “stay in place” (in situ). If they don’t spread, they are not life-threatening.  Some researchers call DCIs “Stage Zero” cancer. 

A recent study found that DCIS incidence rose from 1.87 per 100,000 in the mid-1970s to 32.5 in 2004,” he adds. “That’s a more than 16-fold increase over 30 years, and it’s pretty much all due to the introduction of mammographic screening.” (Mammograms are especially good at spotting DCIs. Unfortunately, they are not as good at finding the very aggressive cancers that are most likely to kill us.) )

“When it comes to DCIS, we don’t have a good handle on what percentage of DCIS will progress to invasive cancer, but we do know that a significant percentage will not.” For that reason, some argue that we should not tell patients that DCIS are “pre-cancerous.”  Labeling them “Stage Zero” would be more accurate.

Nevertheless, precisely because we don’t know, “oncologists tend to treat them all the same,” says Gorski.  “In other words, over diagnosis leads to overtreatment.”

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Navigators: The Folks Who Will Help You Surf the New Insurance Exchanges

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Over at Healthinsurance.org, I’ve addressed some “frequently asked questions” about the “navigators” who will help individuals and small business find the coverage they want in the new Exchanges. 

— Who Will Become Navigators?

—  Can Insurance Agents and Brokers Apply to Be Navigators? (Wouldn’t that create a conflict of interest?)

—  Just How Will Navigators Help People Sort Out Their Options in the Exchanges?

—  How Much Training Will They Receive?

–Finally, many people worry that the “navigators” just won’t be able to handle the heavy traffic. Giving the American public the information it will need about Obamacare is an enormous task. Will these navigators be up to it?

The answer to that last question is that the navigators will have help.  Patient advocacy groups, the states, and county health agencies will pitch in.  The federal government  also is launching a marketing program, “Enroll America” that will urge mothers to nag their uninsured 20-something and 30-something sons. (Seriously– and I expect that in many cases, this will be effective.)

Meanwhile insurers will be eager to draw young, healthy customers into the Exchanges. This means that they will invest in marketing campaigns designed to let 20-somethings and 30-somethings know that the vast majority will be eligible for generous government subsidies.

Just one example: Blue Cross and Blue Shield of Illinois already has launched a “Be Covered Illinois” campaign. The campaign is being funded by the insurer, and carried out by various community groups:  

Keep in mind that if insurers mislead customers about their offerings, those customers will have an opportunity to pick a different plan a year later. And under the ACA, they will have “navigators” to help them make a better choice.

Insurers know this. They  also are well aware  that under the new ACA rules that regulate them, a health insurance company will have to draw—and keep—a large share of the market’s customers in order to survive financially. For that reason, I suspect that savvy insurers will make a major effort to provide information about specific plans that will attract customers who will want to stick with those plans.

For my answers to the first four questions above, go to Health Insurance.org, click on the question and the answer will pop up.

Obamacare’s Opponents Spread Doubt and Confusion About Small Business Exchanges

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In the past, I have reported on misinformation about healthcare reform going viral. It has happened again, and this time, reform’s critics have outdone themselves.

In March, the Obama administration proposed revising the rules governing insurance marketplaces or “exchanges” where small business owners will be able to pool their buying power, and purchase affordable, high quality insurance for their employees. The change to the rules is small, and it is temporary.

Nevertheless, Obamacare’s critics pounced, and soon began distorting what the administration said. USA Today quoted the Chamber of Commerce (long a foe of reform), claiming that the small business exchanges “will be of little or no value to employers, or by extension, their employees.”

                                     How Small Business Exchanges Lower Premiums

Before considering the charges, let’s review what the health reform law’s Small Business Health Options (SHOP) exchanges offer. Today, insurers charge small companies 18 percent more because the administrative costs of hand-selling policies to small groups are high.

But in the SHOP Exchanges, small businesses automatically become part of large groups. Some will qualify for tax credits.  The Congressional Budget Office (CBO) estimates premiums will fall by 2 percent to 11 percent. Meanwhile those premiums will buy far better coverage. (Policies sold in the SHOP Exchanges will have to meet the high standards set for plans in the individual exchanges).

                             The Proposed Change: What the Administration Actually Said

Now consider the proposed change. Originally, the Affordable Care Act called for opening SHOP exchanges to employees in 2014. First, the employer would choose a tier of insurance. (Bronze, Silver, Gold or Platinum tiers will pay 60 percent to 90 percent of an average group’s covered benefits, with any individual’s out-of-pocket spending capped at roughly $6,000.) Employees would then pick plans from that tier.

But Washington had assumed that states would be eager to help their small businesses by setting up exchanges. Today, only 16 states and the District of Columbia have begun. Now the administration realizes it will need more time to set up the IT that millions of employees will need to navigate exchanges in 34 states.

 HHS still plans to open the exchanges in 2014, but only to employers. They will survey the many plans available, and then pick one for their employees. “Employee Choice” will be delayed – but just for one year. And the postponement will apply only to the 34 states that have not set up exchanges. In 2014, the other 16 states and D.C. can (and probably most will) open exchanges to employees.

“Nearly 40% of small businesses in this country do business in the 17 states implementing their own exchanges,” observes John Arensmeyer, president of Small Business Majority (SBM), a non-profit advocacy group. And “starting next year, small employers will still be able to pool their buying power in the exchanges, giving them the kind of clout large businesses currently enjoy.”

“This is not a failure, it’s a bump in the road,” Small Business Majority’s Rhett Buttle told me.

                                               The Attack Begins

Nevertheless, Robert Laszewski, a long-time health reform critic, jumped on the bump, telling Modern HealthCare: “Offering a single employer all of the exchange options is a complex undertaking . . . a delay means that the exchange isn’t going to offer any advantage over the employer simply staying with their existing insurer.”

Laszewski suggests that “a single employer“ will not be able to choose from all of the exchange options.” This is simply not true. Business owners will choose from all plans in the exchange. As for an employer keeping his “existing” coverage – why would he do that? The policies in the exchanges will offer better coverage for less.

Above, the opening of a post that I wrote for HealthInsurance.org.   To find out more about why Lawzewski’s is bashing small business Exchanges–and what what Time’s Joe Klein, the Wall Street Journal and Wonkblog’s Sarah Kliff had to say– read the entire post on HIO.   You’ll also find out  why some of us think that the importance of “consumer choice” may be “way overblown.”

Doctors Sue Hospitals to Protect Patients; A University Buys Insurance that Doesn’t Protect Students; What Gay Marriage Laws Mean for Gay Coverage . . . . and More

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The newest Health Wonk Review has been posted. This time around, Colorado Health Insurance Insider’s Louise Norris is the host, and it’s an excellent read.

A few highlights:

                                 Doctors Sue Hospitals, Protect Patients

Over at Healthcare Renewal, Roy Poses digs into how doctors are pushing back against hopsitals who put profits above everything else. His article describes two recent lawsuits filed by physician groups alleging that the hospital systems they worked for were sacrificing patient welfare in the name of profit. 

As Louise observes, “the details are sickening to read:  One hospital group encouraged its docs to exaggerate the severity of patient conditions and needlessly admit patients from the ER to hospital beds in order to bill more for their treatment.  Another hospital group that owns three hospitals and also partially owns an ambulance company was making patient transfers (using their own ambulance company despite slower response times) a top priority – to the extent that a doctor’s transfer rate was a factor in bonuses and performance reviews.  An admin email stated that “the performance we are looking for are transfers.”  Wow.  Transfers just for the sake of racking up revenue – patient welfare had nothing to do with it, and was likely compromised when the slower ambulance company was used in cases where the transfer was actually warranted.”

I’m just skimming the surface of the corruption Roy exposes. You really should read his entire post.

Often doctors are afraid to stand up to greedy hospital administrators.  But by banding together, physician groups can stand up for patients.

I would add that, in the past  two doctors— working at separate non-profit hospitals—have told me about hospital administrators pressuring physicians to admit ER patients, even when they did not need to be hospitalized. This is how some hospitals “put heads on beds.” 

                 When Universities Buy Inadequate Insurance for Their Students

On his blog, Duncan Cross tells the story of the Arizona State graduate student who died because his Aetna plan (a student plan purchased through the university) capped how much the insurer would pay out over the course of a lifetime at $300,000. It also didn’t cover prescription drugs.  One might be tempted to blame the insurance company,
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Problems with Health Insurance? Under the Affordable Care Act You Will No Longer Be Alone

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If you sent in your health insurance payment on time, and paid it the way you always have (as a direct withdrawal from you checking count), but made a mistake when you put the checking account number on your payment,  would you expect that your insurer would drop you?

What if your insurer sent you an email a few days after you sent in your payment saying “Your payment has been received? Wouldn’t you assume that you were still insured?

Mike Holden did. He was wrong.

Yesterday, he sent an email explaining his story.  

 “On March 16, I paid my family’s monthly health insurance bill to United Healthcare (UHC) the same way I have for almost a year now. But I was using a new bank account that we set up after a recent move. Unfortunately, I entered the account number incorrectly. It turns out I left off three digits that are part of the account number but listed separately on the checks.”

Holden had no idea that he had made a mistake. On March 20, he received an email from UHC saying “Your payment has been received.”

Yet in April, when he went online to pay his family’s April bill, he was told his coverage had been terminated. He then talked to a customer service representative at UHC and received a letter explaining that he had until March 31 to correct his mistake.

Unfortunately, the letter, which was postmarked March 27, went to his old address. .

He appealed to UHC, explaining the problem and asking that his insurance be reinstated,

He then received a letter telling him that his appeal had been denied:  “United Healthcare Benefit Services follows the guidelines for payments and grace periods defined by the Department of Labor. Your account has been reviewed and the termination remains, as payment was not received within the guidelines provided.”

                          How the Affordable Care Act Brings Us Together

Beginning in 2014, people like Mike Holden will no longer be alone, trying to stand up to insurance companies. Individuals and families who buy their own insurance will be able to purchase coverage in “Exchanges”—marketplaces where insures will be regulated and individuals and families who purchase their own insurance will become part of a large group. There, they will have far more clout than they do now.
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How Will Age and Gender Affect Your Health Insurance Premiums in 2014?

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Below, a guest-post by Kev Coleman,  head of research and data at HealthPocket  http://blog.healthpocket.com/  I recently stumbled onto his blog, and now read it regularly. Coleman  does an impressive job of crunching the numbers  on health care and health care reform—with some surprising results.  

 Under the Affordable Care Act (ACA)  insurers can charge older Americans up to 3 times as much as they would charge a 20-something for exactly the same policy. That might sound steep, but today, in many states, insurers can charge older customers 5 times as much.  

Some politicians and industry analysts have predicted that because the ACA limits the ratio to just 3:1 (or 300%) , this will would drive up health insurance premiums for younger enrollees, particularly those in their twenties.

To determine the credibility of that prediction, HealthPocket examined over 20,000 premium quotes within the individual & family insurance market for men and women ages 23, 30, and 63.  

 We found that in 14 states the average 63-year-old now shells out more than three times what a 23 year old pays. But in six of those states his premium exceeded what a younger customers by less than 310%.  In other words, in these states the 63 year old is paying just slightly more than he would under the ACA.

Moreover, the typical 63 year old was not paying 4 times as much as the 23 year old in any of these states. The most expensive state for the average 63-year was Delaware, where his premium would be 382% higher. And Delaware is an outlier.  Nationally the difference in premiums between applicants age 63 and applicants age 23 averaged just 260%, making it unlikely that the ACA’s 300% limit on age-adjusted premiums will be a factor that drives younger Americans premiums skiy-high.

However, these averages mask the differences in premiums between men and women. The majority of states allow insurers to offer women and men different premiums even if the women and men share the same age, health status, and smoking status.

 

[As I have reported in the past, when women buy their own health insurance in the individual market, they must lay out an extra $1 billion a year, simply because they are women. Insurers explain that women cost them more, even if policies don’t cover maternity, because “they are more likely to visit doctors, get regular check-ups, take prescription drugs, and have certain chronic illnesses.” In other words, women are penalized for taking care of themselves. MM]

 HealthPocket’s analysis reveals that female health insurance applicants average higher insurance premiums at age 23 than men of the same age. When comparing 30 year-olds to 23 year-olds, 30-year-old women faced an even higher gender-adjusted premium.

 
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The Psychological Impact of Medical Training on Physicians

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In the first chapter of his landmark work, Medical Ethics, Thomas Percival calls on physicians to ‘‘unite tenderness with steadiness’’ in their care of patients.

Percival wrote those words in 1803.  Today, they sum up what healthcare reform is asking of 21st century physicians: “Patient-centered medicine” requires that a doctor combine strength with compassion. A physician needs courage, fortitude—and great empathy. But, as I suggest in the post below, the hazing that turns medical education into an endurance test does not encourage tenderness.  Teaching through humiliation and intimidation only conditions doctors-in-training to develop a “tough hide” as they learn to take abuse without showing emotion.  

This is a process that trains young physicians to bury their feelings argue Jack Coulehan, M.D. and Peter C. Williams, Ph.D. in “Vanquishing Virtue,” a superb analysis of the “Impact of Medical Education” published in the journal, Academic Medicine, in 2001.  

 “The hot-house atmosphere is psychologically and spiritually brutal,” they write, and too often, “students receive little emotional support from faculty” or “role-model physicians.” Instead, students report feelings of paranoia: “I’m always being watched.”

Coulehan and Williams stress that some students survive, spiritually intact: “Certain personal characteristics of the student such as gender, belief system,” and age probably play roles, helping some students escape the most harmful effect of the conditioning. Medical schools that support “family medicine” and offer courses in “communication skills medical ethics, humanities, and social issues in medicine” can help.  

Nevertheless, in many instances, a poisonous, punitive culture saps the spirit of young doctors as they learn to “shut down” emotionally.

Little wonder that medical students who have endured this rite of passage resent the idea that nurse practitioners can do the work they do, and should receive equal pay and equal respect when providing the same services.  These physicians object, because they feel they have paid very high “dues” to earn the title “Doctor. “

“Physicians have every right to believe that the social utility of their work demands respect, Coulehan and Williams acknowledge.

 “However, the duration, rigor, intensity, and abusiveness of today’s medical education also engenders a sense of entitlement to high income, prestige, and social power.” In essence many believe (rightly), that they paid a high price to earn that MD after their name—not just in the form of high tuition ,but in the form of  “long hours, deferred gratification, great responsibility–—which then warrant very high benefits in return, the cultural equivalent of ‘‘MD’’ license plates.

This leads to that sense of entitlement,” a belief “that physicians are due a special status in the world of healthcare not just because they have worked so hard, but because they have been so abused.”

While their grievance is justified, a sense of having been abused it is not a strong foundation for self-respect. Nor is it is a good reason to resent NPs. Rather, young physicians should resent a system designed to bully rather than to nurture, and vow not to repeat the ritual when they train doctors.

                                    The Explicit Curriculum vs. The Hidden Curriculum

 Coulehan and Williams explore the tension between the explicit curriculum of medical school, and a hidden curriculum, the unwritten code that shapes the values and behaviors of many physicians. “The explicit curriculum stresses empathy and associated listening and responding skills, the relief of suffering, the importance of trust and fidelity, and a primary focus on the patient’s best interest.”

By contrast, the implict curriculum, what they call “tacit learning,” stresses “detachment, wariness, and distrust of emotions, patients, insurance companies, administrators, and the state.” This is how residents learn to survive.

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